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MANUAL 


MILITARY  SURGERY, 


HINTS  ON  THE  EMERGENCIES  OF  FIELD, 
CAMP  AND  HOSPITAL  PRACTICE. 


By  S.  D.  gross,  M.  D. 

Professor  of  Surgery  in  the  Jefferson  Medical  College,  of  Philadelphij 


J.  W.  RANDOLPH, 

121  MAIN  STREET,  RICHMOND,  Va. 

1862. 


In  view  of  the  great  want  of  some  convenient  work  on-  Military 
Surgery,  we  present  a  valuable  little  Treatise  recently  published  by 
Dr.  S.  D.  Gross,  of  Philadelphia.  The  book  trade  between  the  two 
sections  of  the  continent  having  been  interrupted,  it  has  rendered  it 
impossible  for  Dr.  G's.  publishers  to  furnish  the  work  to  the  Southern 
Public.  We  avail  ourselves  of  the  copy  recently  published  in  the 
Southern  Medical  and  Surgical  Journal,  Augusta,  Geo. 


C.  H.  WYNNE,  PRINTER,  RICHMOND. 


MILITARY  SURGERY, 


CHAPTER  I. 

HISTORICAL  SKETCH  OF  MILITARY  SURGERY. 

• 

The  duties  and  requirements  of  military  are  essentially  sim- 
ilar to  those  of  civil  surgery.  It  is  founded  upon  the^  same 
knowledge  of  anatomy,  medicine  and  the  associate  sciences ; 
it  demands  the  same  qualifications,  physical,  moral  and  intel- 
lectual. The  difference  consists  in  the  application  of  our 
knowledge  rather  than  in  its  range  or  depth.  The  civil  surgeon 
remains  at  home;  the  military  follows  the  army,  examines 
recruits  for  the  public  service,  and  superintends  the  healtbiof 
the  troops.  If  the  former  is  well  educated,  he  will  be  quite 
as  competent,  at  any  time,  as  the  latter  to  perform  thcso 
duties;  for  the  emergencies  of  civil  are  often  not  less  trying 
than  those  of  military  practice,  although  they  may  not  be  on 
so  lirge  a  scale. 

The  best  civil  have  often  also  been  the  best  military  sur- 
geons. In  proof  of  this  assertion  it  is  necessary  only  to  refer 
to  the  names  of  Pare,  Wiseman,  Schmucker,  Kern,  Larrey, 
Guthrie,  Charles  Bell,  Alcock,  Thomson,  Ballingall  and  Mac- 
leod,  of  Europe;  or  to  those  of  Rush,  Jones,  Thacher,  Mann 
and  Horner,  of  our  own  country. 

Military  surgery  occupies,  at  the  present  day,  a  deservedly 
high  rank  in  the  estimation  both  of  the  profession  and  of  the 
public.  The  war  in  the  Crimea,  the  mutiny  in  India  and 
the  recent  convulsions  in  Italy,  all  attended  with  so  much 


4  MILITARY   SURGERT. 

waste  of  blood  and  life,  have  attracted  to  it  the  universal 
attention  of  the  profession ;  and  the  revolutionary  movements 
now  in  progress  in  our.  own  country  invest  it  with  a  new  and 
fearful  interest  to  every  American  physician.  Its  praises  have 
been  sung  by  Homer,  and,  in  all  ages  of  the  world,  govern- 
ments have  extended  to  it  a  fostering  hand.  As  "a  distinct 
branch,  however,  of  the  healing  art,  it  dates  back  no  further 
than  the  early  part  of  the  sixteenth  century,  when  it- was 
inaugurated  by  Ambrose  Pare,  by  the  publication  of  his 
treatise  on  *^  Gunshot  Wounds,"  the  fruits  of  his  observations 
in  the  French  army  in  Italy.  This  man,  who  was  surgeon  to 
four  successive  kings,  was  an  eye-witness  of  the  numerous 
French  campaigns,  from  1536,  down  to  the  battle  of  Moncon- 
tour,  in  1569,  a  period  of  thirty-three  years.  His  popularity, 
both  as  a  civil  and  military  surgeon,  was,  up  to  that  time, 
without  a  parallel.  The  soldiers  worshipped  him ;  and  the 
success  of  more  than  one  siege,  as  well  as  of  one  battle,  was 
due  almost  exclusively  to  the  wonderful  influence  of  his  pres- 
ence. His  treatise  on  "  Gunshot  Wounds  "  appeared  towards 
the  middle  of  the  sixteenth  century,  and,  after  having  passed 
thsough  various  editions,  was  ultimately  incorporated  in  his 
surgical  writings,  published  nearly  a  quarter  of  a  century 
later. 

In  England,  the  earliest  work  on  military  surgery  was  that 
of  Thomas  Gale,  entitled  a  *'  Treatise  on  Gunshot  Wounds," 
designed  chiefly  to  confute  the  errors  of  some  of  his  contem- 
poraries, respecting  the  supposed  poisonous  nature  of  these 
lesions.  Gale  was  born  in  1507,  and  after  having  served  in 
the  army  of  King  Henry  YIII.,  at  Montrieul,  and  also  in 
that  of  King  Philip,  at  St.  Quintin,  finally  settled  at  London, 
where  he  acquired  great  distinction  in  his  profession.  In 
1639  appeared  the  work  of  J.  Woodall,  "The  Surgeon's 
Mate ;  or,  Military  and  Domestic  Surgery."  He  was  surgeon 
under  Queen  Elizabeth,  by  whom  he  was  sent  to  France, 
along  with  the  troops  that  were  dispatched  to  the  assistance  of 
Henry  IV.  and  Lord  Willoughby.     In  1676;  llichard  Wise- 


MILITARY   SURGERY.  5 

man,  sergeant-surgeon  to  King  Charles  IT.,  published  his 
famous  "  Chirurgical  Treatises,"  one  of  which  was  expressly 
devoted  to  the  consideration  of  gunshot  wounds.  Two  years 
after  this  a  treatise  on  gunshot  wounds  was  published  at  Lon- 
don, by  John  Brown,  aho  surgeon  to  Charles.  He  was  a  man 
of  eminence,  and  served  with  much  credit  in  the  Dutch  war 
of  1665.  The  next  English  work  on  military  surgery  appeared 
in  1744,  from  the  pen  of  John  Ranby,  sergeant-surgeon  to 
George  II.,  under  the  title  of  ''  The  Method  of  Treating  Gun- 
shot Wounds."  After  Ranby  came  the  imperishable  work  of 
John  Hunter,  familiar  to  every  reader  of  English  surgical 
literature.  The  part  relating  to  gunshot  wounds  was  founded 
upon  his  observations  made  while  serving  as  staff-surgeon  at 
Belleisle  and  in  Portugal,  and  is  one  of  the  most  precious  leg- 
acies of  the  last  century,  near  the  close  of  which  it  appeared. 

The  present  century  has  supplied  quite  a  number  of  works 
on  military  surgery,  as  is  shown  by  the  publications  of  Larrey, 
Hennen,  Hecker,  Augustin,  Guthrie,  Thomson,  Hutchinson, 
Rallingall,  Baudens  and  others,  which  have  contributed  so 
much  to  the  elevation  of  this  department  of  the  healing  art. 
Some  of  these  works  have  been  re-issued  in  this  country,  and 
have  acquired  a  wide  celebrity. 

We  must  not  forget,  in  this  rapid  enumeration  of  works  on 
military  surgery,  the  "Manuel  de  Chirurgien  d'Armee''  of 
Baron  Percy,  published  at  the  commencement  of  the  revolu- 
tionary war  in  France.  It  is  a  model  of  what  such  a  treatise 
ought  to  be. 

The  only  work  on  this  department  of  science  yet  furnished 
in  this  country,  is  that  of  the  late  Dr.  James  Mann,  published 
at  Dedham,  Massachusetts,  in  1816.  It  is  entitled  "  Medical 
Sketches  of  the  Campaigns  of  1812,  '13  and  '14,"  and  forms 
a  closely-printed  volume  of  upwards  of  three  hundred  octavo 
"pages. 

The  latest  treatise  on  this  subject  in  the  English  language 
is  that  of  Dr.  George  H.  B.  Macleod,  now  Professor  of  Sur- 
gery at  Glasgow,  entitled  "Notes  on  the  Surgery  of  the  War 


6  MILITARY   SURGERY. 

in  the  Crimea;  with  remarks  on  the  Treatment  of  Gunshot 
Wounds."  It  is  a  work  of  intense  interest,  written  with 
great  ability  by  an  accurate  and  diligent  observer,  and  is 
worthy  of  a  place  in  every  medical  library.  To  this  work 
frequent  reference  will  be  made  in  the  following  pages. 

To  Dr.  Lewis  Stromeyer,  Physician  of  the  Royal  Han- 
overian Army,  we  are  indebted  for  the  most  recent  German 
work  on  military  surgery.  It  was  issued  in  1858,  under  the 
title  of  ^'Maximen  der  Kriegsheilkunst,'^  in  two  duodecimo 
volumes,  to  which  a  Supplement  was  added  in  the  early  part 
of  the  present  year.  A  more  valuable  contribution  to  this 
department  of  surgery  could  hardly  be  imagined. 

Besides  the  above  more  recent  works,  the  reader  should 
carefully  study  the  ^'Principles  of  Military  Surgery,"  by  the 
late  Dr.  John  Hennen,  one  of  the  most  zealous  and,  distin- 
guished military  surgeons  that  Great  Britain  has  yet  produced; 
a  man  of  vast  experience  and  of  the  most  enlightened  views 
upon  everything  he  has  touched  with  his  pen. 

Perhaps  the  most  systematic  work  on  the  subject  in  the 
English  language  is  that  of  Sir  George  Ballingall,  entitled 
^'  Outlines  of  Military  Surgery,"  the  last  edition  of  which, 
the  fourth,  appeared  only  recently  at  Edinburgh,  where  the 
author  held  for  many  years  the  chair  of  military  surgery ;  for 
a  long  time,  we  believe,  the  only  one.  in  Great  Britain.  It  is 
a  production  of  much  merit,  and  is  destined  to  maintain  a 
very  high  rank  in  this  species  of  literature. 

The  works  of  the  late  Mr.  George  Guthrie  also  deserve 
attentive  study;  they  are  written  with  great  clearness  and 
ability,  and  embody  the  results  of  an  immense  experience, 
acquired  during  many  years  of  arduous  and  faithful  labor  and 
observation  in  the  British  army.  I  have  always  regarded  the 
works  of  this  great  man  as  among  the  iJQOst  valuable  contribu- 
tions, not  only  to  military  surgery,  but  to  surgery  in  general, . 
in  the  English  language. 

With  these  works  before  him,  the  student  of  military  sur- 
gery cannot  fail  to  make  himself  in  a  short  time  perfectly 


MILITARY   SURGERY.  7 

familiar  with  everything  pertaining  to  the  subjects  of  which 
they  treat.  He  should  also  provide  himself  with  a  copy  of 
the  excellent  little  volume  entitled  "  Hints  on  the  Medical 
Examination  of  Kecruits  for  the  Army,"  by  the  late  Dr. 
Thomas  Henderson,  formerly  Professor  of  Medicine  in  Colum- 
bia College,  Washington  City.  A  new  edition  of  it  was  pub- 
lished a  few  years  ago  by  Dr.  Richard  H.  Coolidge,  of  the 
United  States  army. 

Although  we  have  long  had  one  of  the  most  respectable 
and  thoroughly  organized  army  and  navy  medical  staffs  in  the 
world,  our  country  has,  nevertheless,  not  produced  one  great 
military  surgeon ;  simply,  it  may  be  presumed,  because  no 
opportunity  has  occurred  since  the  establishment  of  our  gov- 
ernment in  which  the  men  in  the  public  service  could  distin- 
guish themselves.  Their  aid  has  been  required  in  the  duello 
and  in  skirmishes  rather  than  in  great  battles,  such  as  have  so 
often  characterized  the  movements  of  the  armies  of  the  Old 
"World.  We  make  no  exception  in  this  remark  in  favor  even 
of  the  battles  that  were  fought  during  the  llevolution,  and 
during  the  Late  War,  as  it  has  usually  been  designated,  with 
Great  Britain.  Those  engagements  were,  for  the  most  part, 
comparatively  bloodless.  Happily  living  under  a  flag  which, 
until  recently,  commanded  alike  the  respect  and  the  admira- 
tion of  all  nations,  belonging  to  a  government  which  was  at 
peace  with  all  foreign  powers,  the  medical  and  surgical  staffs 
of  the  public  service  had  little  else  to  do  than  to  prescribe  for 
such  diseases  as  are  incident  to  civil  practice.  America  has 
never  witnessed,  and  we  trust  in  God  she  never  may  witness, 
such  carnage  as  that  which  attended  the  footsteps  of  Napo- 
leon at  the  bridge  of  Lodi,  at  Leipzig,  at  Dresden  and  at  Wa- 
terloo ;  or  which,  more  recently,  characterized  the  exploits  of 
the  English,  French  and  Russian  forces  in  the  Crimea ;  or  of 
the  French,  Italian  and  Austrian  armies  in  Italy;  or  of  the 
English  soldiers  during  the  late  rebellion  in  India.  Nor  has 
she  ever  been  engaged  in  one  great  naval  battle  similar  to  that 
of  La  Hogue,  Toulon,  Trafalgar  or  Aboukir.    A  number  of 


8  MILITARY  SURGERY. 

highly  respectable  physicians  accompanied  our  army  to  Mex- 
ico, but  they  returned  without  any  special  laurels,  and  with- 
out any  substantial  contributions  to  military  medicine  and 
Birgery. 


CHAPTER  II, 
IMPORTANCE  OF  MILITARY  SURGERY. 

It  is  impossible  for  any  civilized  nation  to  place  too  high 
an  estimate  upon  this  branch  of  the  public  service.  Without 
the  aid  of  a  properly  organized  medical  staff,  no  army,  how- 
ever well  disciplined,  could  successfully  carry  on  any  war, 
even  when  it  is  one,  as  that  which  is  now  impending  over  us,* 
of  a  civil  character.  No  men  of  any  sober  reflection  would 
enlist  in  the  service  of  their  country,  if  they  were  not  posi- 
tively certain  that  competent  physicians  and  surgeons  would 
accompany  them  in  their  marches  and  on  the  field  of  battle, 
ready  to  attend  to  their  diseases  and  accidents.  Hence  mili- 
tary surgery,  or,  more  correctly  speaking,  military  medicine 
and  surgery,  has  always  occupied  a  deservedly  high  rank  in 
public  estimation. 

Dionis,  a  surgeon  far  in  advance  of  his  age,  in  referring  to 
the  value  of  medical  services  to  soldiers,  exclaims,  with  a 
burst  of  eloquence  :  "  We  must  then  allow  the  necessity  of 
chirurgery,  which  daily  raises  many  persons  from  the  brink  of 
the  grave.  How  many  men  has  it  cured  in  the  army  !  How 
many  great  commanders  would  have  died  of  their  ghastly 
wounds  without  its  assistance !  Chirurgery  triumphs  in  ar- 
mies and  in  sieges  1  'Tis  true  that  its  empire  is  owned ;  'tis 
there  that  its  effects,  and  not  words,  express  its  eulogium/' 

The  confidence  reposed  by  soldiers  in  the  skill  and  human- 
ity of  their  surgeon  has  often  been  of  signal  service  in  sup- 
porting them,  when  exhausted  by  hunger  and  fatigue,  in  their 


MILITARY  SURGERY.  9 

struggles  to  repel  the  advancing  foe,  or  in  successfully  main- 
taining a  siege  when  the  prospects  of  speedy  surrender  was  at 
hand.  Who  that  is  versed  in  the  history  of  our  art  does  not 
remember  with  what  enthusiasm  and  resolve  Ambrose  Pare, 
the  father  of  French  surgery,  inspired  the  souls  of  the  half- 
starved  and  desponding  garrison  at  Metz,  in  1552,  when  be- 
sieged by  100,000  men  under  the  personal  command  of 
Charles  V.  ?  Sent  thither  by  his  sovereign,  he  was  intro- 
duced into  the  city  during  the  night  by  an  Italian  captain ; 
and  the  next  morning,  when  he  showed  himself  upon  the 
breach,  he  was  received  with  shouts  of  welcome.  ''We  shall 
not  die,"  the  soldiers  exclaimed,  "even  though  wounded; 
Pare  is  among  us.''  The  defense  from  this  time  was  con- 
ducted with  renewed  vigor,  and  the  French  army  ultimately 
completely  triumphed,  through  the  sole  influence  of  this  illus- 
trious surgeon.  # 

No  man  in  the  French  army  under  Napoleon  rendered  so 
many  and  such  important  services  to  the  French  nation  as 
— |Larrey,  the  illustrious  surgeon  who  accompanied  that  mighty 
warrior  in  his  various  campaigns,  everywhere  animating  the 
troops  and  doing  all  in  his  power  to  save  them  from  the  de- 
structive effects  of  disease  and  injury.  His  humanity  and 
tenderness  was  sublime;  and  so  highly  was  his  conduct,  as  an 
honest,  brave,  and  skillful  surgeon,  appreciated  by  Napoleon, 
that  he  bequeathed  him  a  large  sum,  with  the  remark  that 
"  Larrey  was  the  most  virtuous  man  he  had  ever  known." 


CHAPTER.   III. 
QUALIFICATIONS   AND   DUTIES    OF  MILITARY   SURGEONS. 

It  is  of  paramount  importance  that  none  but  men  of  the 
best  talent  and  of  the  highest  education  should  be  received 
into   the  public  service. ,  Kigid  as   the  examination  of  the 


10  MEDICAL  SURGERY. 

army  and  navy  medical  boards  already  is,  there  is  need  of  in- 
creased rigor,  in  order  that  none  may  be  admitted  who  are  not 
thoroughly  prepared  for  the  discharge  of  their  responsible  du- 
ties. Equal  vigilance  should  be  exercised  in  regard  to  the 
introduction  of  physicians  and  surgeons  into  the  volunteer  ser- 
vice. Every  regiment  should  be  provided  with  an  able  medi- 
cal head,  a  man  ready  for  every  emergency,  however  trying  or 
unexpected;  a  man  skilled  in  the  diagnosis  and  treatment  of 
diseases,  and  competent  to  perform  any  operation,  whether 
small  or  large,  on  the  spur  of  the  moment.  To  do  this,  he 
must  be  more  than  a  mere  physician ;  he  must  be  both  a  phy- 
sician and  surgeon,  in  the  true  sense  of  the  terms,  otherwise 
he  will  be  unfit,  totally  unfit,  for  his  position.  He  must  have 
been  educated  in  the  modern  schools ;  be  of  undoubted  cour- 
age, prompt  to  act,  willing  to  assume  responsibility,  humane 
and  sympathizing,  urbane  and  c#irteous  in  his  manners ;  in 
short,  a  medical  gentleman,  as  well  as  a  medical  philosopher, 
not  hesitating,  if  need  be,  to  perform  the  most  menial  services, 
and  to  do  all  he  can  to  preserve  the  health  and  the  lives  o^ 
the  soldiers  committed  to  his  care.  The  white-gloved  gentry, 
such  as  figured  in  some  of  the  regiments  that  went  to  Mexico, 
have  no  business  in  the  service  ;  their  time  can  be  much  bet- 
ter  spent  in  the  discharge  of  their  domestic  duties,  in  the 
practice>-of  their  neighborhood,  and  in  the  contemplation^  at  a 
distance,  of  the  miseries  of  war. 

It  is  much  to  be  feared  that,  from  the  rapid  manner  in 
which  our  volunteers  have  been  hurried  together,  many  medi- 
cal men,  old  as  well  as  young,  have  already  been  admitted  into 
the  service  utterly  unfit  for  the  ofiice.  If  this  be  the  case,  let 
our  authorities,  warned  by  the  past,  be  more  circumspect  in  re- 
gard to  the  future.  Above  all,  let  them  see  that  the  medical 
stafl"s  of  the  brave  volunteers  of  the  country  be  not  defiled  by 
charlatans  and  unworthy  men,  between  whom  and  the  regular 
practitioners  there  cannot  possibly  be  any  professional,  much 
less  social  intercourse,  either  in  civil  or  military  practice. 
The  medical  men  should  be  on  the  best  possible  terms  with 


MEDICAL  SURGERY.  11 

each  other ;  all  causes  of  discord  and  bickering  among  them- 
selves should  be  studiously  obviated,  and  speedily  suppressed, 
if,  unfortunately,  they  should  arise.  Concert  of  action  on  the 
part  of  the  medical  corps  is  indispensable  to  the  success  of  the 
medical  operations  of  an  army. 

Every  regimental  surgeon  should  have  at  least  two  assist- 
ants in  time  of  peace,  or  during  the  inactivity  of  the  troops 
under  his  charge ;  when  on  active  duty,  on  the  contrary,  the 
number  should  at  least •  be  double,  especially  in  the  face  of  an 
anticipated  bloody  engagement.  These  assistants  should  be 
selected  solely  with  reference  to  their  competency ;  they 
should,  like  the  principal,  be  eminently  intelligent,  and  ready, 
in  case  of  emergency,  to  perform  any  operation  that  occasion 
may  demand.  Every  brigade  should  have  its  brigade  sur- 
geon, who  should  exercise  a  supervisory  control  over  the  regi- 
mental surgeons,  principals  as  well  as  assistants ;  as  every 
State  should  have  its  surgeon-general  or  medical-director, 
whose  duty  it  should  be  to  superintend  the  whole  medical 
arrangements,  seeing  that  the  candidates  for  the  medical  de- 
partment of  the  service  be  subjected  to  a  rigid  examination, 
attending  to  the  purchase  of  medicines  and  instruments,  provid- 
ing suitable  nurses,  inspecting  the  quarters;  stores  and  provi- 
sions, that  nothing  of  an  unwholesome  character  may  find  its 
way  into  the  ranks,  pointing  out  the  proper  location  of  camps, 
and  the  construction  of  hospitals,  and  giving  general  instruc- 
tions in  regard  to  military  hygiene,  or  the  best  means  of 
avoiding  disease  and  accident. 

Prior  to  every  engagement  at  all  likely  to  be  severe  or  se- 
rious, a  proper  number  of  men  should  be  detailed  for  the  pur- 
pose of  rendering  prompt  assistance  to  the  wounded,  and  car- 
rying them  off  the  field  of  battle  to  the  hospitals,  or  tents, 
erected  for  their  accommodation  and  treatment.  Unless  this 
be  done  as  a  preliminary  step,  much  suffering  will  inevitably 
be  the  consequence,  if  not  great  confusion,  highly  prejudicial 
to  the  issue  of  the  combat.  So  fully  aware  are  the  leaders 
and  sub-commanders  of  eur  armies  of  this  fact,  that  they  never 


12  M  MBDICAli   SURGERY. 

permit  any  man  to  fall  out  of  the  ranks,  during  an  engage- 
ment, to  perform  this  service. 

While  the  battle  is  progressing,  it  is  the  duty  of  the  sur- 
geon and  of  his  assistants  to  remain  in  the  rear  of  the  com- 
batants, as  much  as  possible  out  of  harm's  way,  but  at  the 
same  time  ready  and  on  the  watch  to  render  the  promptest 
possible  aid.  They  must  be  Argus-eyed,  and  in  the  full  pos- 
session of  their  wits.  One  of  the  leading  differences  between 
military  and  civil  practice  is  the  instantaneous  action  so  often 
demanded  by  the  one  and  the  delay  so  frequently  admitted  by 
the  other. 

The  first  duty  of  every  surgeon  is  to  the  oflGicers  and  men 
of  his  own  corps ;  but  on  the  field  of  battle,  or  soon  after  the 
battle  is  over,  he  is  often  brought  in  contact  with  the  members 
of  other  regiments,  or  even  with  the  wounded  of  the  enemy ; 
and  under  such  circumstances  the  dictates  of  humanity,  not 
less  than  the  "usages  of  war,  demand  that  he  should  render  his 
services  wherever  theiy  may  be  likely  to  be  useful.  The  med- 
ical officers  of  the  contending  parties  sometimes  meet  upon 
such  occasions,  and,  when  this  is  the  case,  their  conduct  should 
invariably  be  characterized  by  the  courtesy  of  the  gentleman, 
not  the  asperity  of  the  enemy.  They  should  not  forget  thart 
they  are  brethren  of  the  -same  noble  profession,  acting  in  the 
capacity  of  ministering  angels  to  the  sick  and  dying.  Coun- 
try and  cause  alike  should  be  forgotten  in  generous  deeds. 

By  the  usages  of  war  in  all  civilized  countries,  the  surgeons 
are  always  respected  by  the  enemy  if,  during  an  engagement, 
they  happen  to  fall  accidentally  into  their  hands.  Their  lives 
are  regarded  as  sacred,  the  more  so,  as  they  are  comparatively 
defenseless.  They  are  not,  however,  during  the  rage  and 
smoke  of  the  battle-field,  always  easily  distinguishable  from 
the  other  officers,  or  even  the  common  soldiers.  The  green 
sash,  their  distinctive  badges  of  office,  does  not  always  afford 
them  immunity,  because  it  is  not  always  recognized;  and  it  is 
worthy  of  consideration  whether,  as  an  additional  safeguard, 
the  word  "surgeon"  should  not  be  embroidered  in  legible 


MEDICAL   SURGERT.  13 

characters  upon  a  piece  of  cloth,  to  be  thrown  across  the  chest 
in  time  of  battle.  The  significance  of  such  a  badge  could  not 
be  mistaken  by  friend  or  foe,  and  would  be  the  means  of 
saving  many  valuable  lives. 


CHAPTER  IV. 
MEDICAL  EQUIPMENTS,  STORES  AND  HOSPITALS. 

Every  regiment,  or  body  of  military  men,  should  be  amply 
provided,  in  time  of  war,  with  the  means  of  conveying  the 
wounded  and  disabled  from  the  field  of  battle.  For  this  pur- 
pose suitable  carriages  and  litters  should  constantly  be  in 
readiness.  The  carriages  should  be  built  in  the  form  of  light 
wagons,  drawn  each  by  two  horses ;  with  low  wheels,  easy 
springs,  and  a  large,  wide  body,  furnished  with  a  soft  mattress 
and  pillows,  and  capable  of  accommodating  not  less  than  eight 
or  ten  persons,  while  arrangements  might  be  made  at  the  side 
for  seating  a  number  more,  as  in  the  French  voiture.  As  a 
means  of  protection  against  the  sun  and  the  rain,  it  should 
have  a  light  cover  of  oil  cloth  or  canvas. 

A  great  number  of  Utters^  or  bearers,  will  be  found  de- 
scribed in  treatises  *n  military  surgery;  but  I  am  not  ac- 
quainted with  any  which  combine  so  much  simplicity  and 
cheapness,  with  lightness  and  convenience,  as  one  which, 
after  a  good  -deal  of  reflection,  I  have  just  devised.  It  con- 
sists of  two  equal  parts,  conducted  at  the  ends  by  stout 
hinges,  the  arrangement  being  such  as  to  permit  of  their 
being  folded  for  the  more  easy  transportation  on  the  field  of 
battle.  Each  part  has  a  side  piece  of  wood,  three  feet  four 
inches  long,  by  two  inches  in  depth,  and  an  inch  and  a  half 
in  thickness,  the  free  extremity  terminating  in  a  slightly 
curved  handle.  The  side  pieces  are  united  by  four  traverses, 
and  the  entire  frame  is  covered  with  ducking,  twenty-four 


14  MEDICAL   SURGERY. 

inches  in  widtli.  Thus  constructed,  the  apparatus  is  not  only 
very  light,  so  that  any  one  may  easily  carry  it,  or,  indeed, 
even  three  or  four  at  a  time,  but  remarkably  convenient  both 
for  the  transportation  of  patients,  and  for  lifting  them  in  and 
out  of  the  wagons,  which  should  always  be  at  hand  during  an 
engagement.  Moreover,  by  means  of  side  straps,  provided 
with  buckles,  it  will  answer  extremely  well  for  a  bed-chair,  so 
necessary  in  sickness  and  during  convalescence,  the  angle  of 
flexion  of  the  two  pieces  thus  admitting  of  ready  regulation. 
In  carrying  the  wounded  off  the  field,  the  labor  may  easily  be 
performed  by  two  men,  especially  if  they  use  shoulder-straps 
to  diffuse  the  weight  of  the  burden.  The  body,  in  hot 
weather,  might  be  protected  with  an  oil  cloth,  while  the  face 
might  be  shielded  from  the  sun  with  a  veil  or  handkerchief.  A 
pillow  for  the  head  can  be  made  with  the  coat  of  one  of  the 
carriers. 

Besides  these  means,  every  regiment  should  be  furnished 
"with  an  ambulance,  or,  as  the  term  literally  implies,  a  move- 
able hospital,  that  is,  a  place  for  the  temporary  accommodation 
and  treatment  of  the  wounded  on  the  field  of  battle.  It 
should  be  arranged  in  the  form  of  a  tent,  and  be  provided 
with  all  the  means  and  appliances  necessary  for  the  prompt 
succor  of  the  sufferers.  The  materials  of  which  it  consists 
should  be  as  light  as  possible,  possess  every  facility  for  rapid 
packing  and  erection,  and  be  conveyed  from  point  to  point  by 
a  wagon  set  apart  for  this  object.  The  ambulance,  for  the 
invention  and  improvement  of  which  we  are  indebted  to  two 
eminent  French  military  surgeons,  Percy  and  Larrey,  is 
indispensable  in  every  well-regulated  army. 

This  temporary  hospital  should  be  placed  in  an  open  space, 
convenient  to  water,  and  upon  dry  ground,  with  arrangements 
for  the  free  admission  of  air  and  light,  which,  next  to  pure 
air,  is  one  of  the  most  powerful  stimulants  in  all  cases  of 
accident  attended  with  excessive  prostration.  The  direct  rays 
of  the  sun,  in  hot  weather,  must  of  course  be  excluded,  and  it 
may  even  be  necessary,  as  in  injuries  of  the  head  and  eye,  to 


MEDICAL   SURGERY.  15 

wrap  the  patient  in  complete  darkness.  A  properly  regulated 
temperature  is  also  to  be  maintained,  a  good  average  being 
about  68°  of  Fahrenheit's  thermometer. 

As  engagements  are  sometimes  begun  after  dark,  or  are 
continued  into  the  night,  an  adequate  supply  of  wax  candles 
should  be  provided,  as  they  will  be  found  indispensable  both 
in  field  and  hospital  practice,  in  performing  operations  and 
dressing  wounds  and  fractures.  Torches,  too,  will  frequently 
be  needed,  especially  in  collecting  and  transporting  the 
wounded.  Bed-pans,  feeding-cups,  spoons,  syringes,  and 
other  appliances  usually  found  in  the  sick  chamber,  will  form 
a  necessary  part  of  the  furniture  of  such  an  establishment. 

The  object  of  the  ambulance  is,  as  already  stated,  to  afford 
prompt  succor  to  the  wounded.  Here  their  lighter  injuries 
are  speedily  dressed,  and  the  more  grave  subjected  to  the  ope- 
rations necessary  for  their  cure.  In  due  time,  the  former  are 
sent  back  to  the  ranks,  while  the  rest  are  conveyed  to  suitable 
lodgings  or  to  permanent  hospitals. 

As  soon  as  practicable,  after  the  hurry  and  confusion 
attendant  upon  a  combat  are  over,  the  surgeon  should  classify 
the  wounded  and  disabled,  taking  care  that  those  laboring 
under  similar  lesions  are  not  brought  inclose  contact;  lest, 
witnessing  each  other's  sufferings,  they  should  be  seized  with 
fatal  despondency. 

Larrey,  in  order  to  meet  the  exigencies  of  the  grand  army 
in  Italy,  constructed  a  flying  ambulance  ;  an  immense,  and, 
at  first  sight,  a  very  cumbersome  establishment.  It  consisted 
of  twelve  light  wagbns,  on  easy  springs,  for  the  transportation 
of  the  wounded;  some  with  two,  others  with  four  wheels. 
The  frame  of  the  former,  which  were  designed  for  flat,  level 
countries,  resembled  an  elongated  cube,  curved  on  the  top;  it 
had  two  small  windows  on  each  side,  with  a  folding  door  in 
front  and  behind.  The  floor  of  the  body,  separable  and  move- 
able on  rollers,  was  covered  with  a  mattre^  and  bolster. 
Handles  were  secured  to  it  laterally,  through  which  the 
sashes  of  the  soldiers  were  passed  in  lifting  the  sick  in  and  out 


16  MEDICAL   SURGERY. 

of  the  carriage,  when,  on  account  of  the  weather,  their  wants 
could  not  be  relieved  on  the  ground.  Each  vehicle  was 
thirtj-two  inches  wide,  and  was  drawn  by  two  horses;  it 
could  conveniently  accommodate  two  patients  at  full  length, 
and  was  furnished  with  several  side-pockets  for  such  articles 
as  might  be  needed  for  the  sufferers. 

The  large  carriage,  drawn  by  four  horses,  and  designed  for 
rough  and  hilly  roads,  was  constructed  upon  the  same  principle 
as  the  small ;  it  had  four  wheels,  and  could  accommodate  four 
persons.  The  left  side  of  the  body  had  two  long  sliding-doors, 
extending  almost  its  whole  length,  so  as  to  permit .  the 
wounded  to  be  laid  in  a  horizontal  position. 

These  carriages  were  used  for  conveying  the  wounded  from 
the  field  of  battle  to  the  hospitals  of  the  lines,  and  combined, 
it  is  said,  solidity  with  lightness  and  elegance. 

The  number  of  men  attached  to  the  flying  ambulance  was 
113,  embracing  a  soldier's  guard  with  twelve  men  on  horse- 
back, a  quartermaster-general,  a  surgeon-raajor,  with  his  two 
assistants  and  twelve  mates,  a  police  officer,  and  a  number  of 
servants.  The  flying  ambulance  was,  in  fact,  a  costly  and 
imposing  establishment,  devised  by  the  humanity  and  in- 
genuity of  the  great  and  good  Larrey,  who  could  never  do  too 
much  for  the  wounded  soldier,  and  whose  presence,  like  that 
of  his  illustrious  countryman.  Pare,  always  served  to  animate 
the  French  troops.  At  one  time  three  divisions  of  the  flying 
ambulance,  equipped  upon  this  grand  scale,  were  upon  the 
field  in  different  parts  of  Italy. 

It  is  not  deemed  necessary  in  a  work  like  this,  to  give  an 
account  of  the  construction  of  hospitals,  properly  so  termed ; 
for,  with  the  railroad  and  steamboat  facilities  which  we  now 
possess,  there  can  be  little  difficulty  in  obtaining  comfortable 
accommodations  for  the  sick  and  wounded  soldiers.  Lodgings 
can  almost  always  be  procured,  in  nearly  every  portion  of  the 
country  where*  a  battle  is  likely  to  be  fought,  in  houses, 
churches,  and  barns.  Temporary  sheds  might  easily  be 
erected  in  a  few.  hours,  with   such  arrangements  as  would 


MEDICAL   SURGEET.  17 

serve  for  the  more  pressing  wants  of  the  wounded.  The  chief 
points  to  be  attended  to,  in  their  construction,  are  sufl&cient 
elevation  of  the  ground  floor  for  the  free  circulation  of  air, 
windows  for  light  and  ventilation,  and  such  a  position  of  the 
fire-place  as  not  to  annoy  the  inmates. 

The  medical  stores  of  the  military  hospital,  whether  tempo- 
rary or  permanent,  include  medicines,  instruments,  and 
various  kinds  of  apparatus,  as  bandages,  oiled  silk,  and  splints. 

It  would  far  transcend  my  limits  were  I  to  enter  fully  into 
all  the  details  connected  with  these  different  topics.  A  few 
brief  remarks  under  each  head  must  suffice  for  my  purpose. 

1st.  In  regard  to  medicines^  a  few  articles  only,  well 
selected  and  arranged  for  ready  use,  will  be  necessary.  It  is 
bad  enough,  in  all  conscience,  for  a  man  to  be  severely  shot 
or  stabbed,  without  physicing  him  to  death.  Let  him  by  all 
means  have  a  chance  for  his  life,  especially  when  he  has 
already  been  prostrated  by  shock  and  hemorrhage.  Food  and 
drink,  with  opium  and  fresh  air,  will  then  do  him  more  good 
than  anything  else.  I  shall  enumerate  the  medicines  upon 
which,  in  my  judgment,  most  reliance  is  to  be  placed  in  this 
kind  of  practice,  according  to  their  known  eflfects  upon  the 
system. 

1.  Anodynes  : — opium,  morphia,  and  black  drop,  or  acetated 
tincture  of  opium. 

2.  Purgatives : — blue  mass,  calomel,  rhubarb,  jalap,  com- 
pound extract  of  colocynth,  and  sulphate  of  magnesia.  Some 
of  these  articles  should  be  variously  combined,  and  put  up  in 
pill  form  for  ready  use. 

3.  Depressants: — tartrate  of  antimony  and  potassa,  ipe- 
cacuanha, and  tincture  of  veratrura  viride. 

4.  Diaphoretics : — antimony,  ipecacuanha,  nitrate  of  po- 
tassa,  morphia,  and  Dover's  powder. 

5.  Diuretics : — nitrate  and  carbonate  of  potassa,  and  col- 
chicum. 

6.  Antiperiodics  : — quinine  and  arsenic. 

7.  Anaesthetics  : — chloroform  and  ether. 


18  MEDICAL   SURGERY. 

8.  Stimulants  : — brandy,  gin,  wine,  and  aromatic  spirits  of 
ammonia. 

9.  Astringents : — acetate  of  lead,  perchloride  of  iron  and 
alum,  tannin,  gallic  acid,  and  nitrate  of  silver. 

10.  Escharotics: — nitric  acid,  acid  nitrate  of  mercury, 
(Bennett's  formula,)  and  Vienna  paste. 

2d.  The  surgical  armamentarium  should  also  be  as  simple 
as  possible.  It  should  embrace  a  small  pocket  case,  with  a 
screw  catheter;  a  full  amputating  case,  with  at  least  three 
tourniquets,  two  saws  of  different  sizes,  and  several  large 
bone-nippers;  and,  lastly,  a  trephiniog  case.  Several  silver 
catheters  of  different  sizes,  a  stomach  pump,  small  and  large 
syringes,  feeding-cups  and  bed-pans  should  also  be  put  up. 

3d.  Under  the  head  of  apparatus  may  be  included  band- 
ages, lint,  linen,  adhesive  plaster,  splints,  cushions,  wadding, 
and  oiled  silk. 

The  bandages,  composed  of  tolerably  stout  muslin,  should 
be  free  from  starch  and  selvage,  well  rolled,,  on  an  average, 
from  two  inches  and  a  quarter  to  two  inches  and  a  half  in 
width  by  eight  yards  in  length.  The  bandage  of  Scultetus, 
very  serviceable  in  compound  factures,  can  easily  be  made,  as 
occasion  may  require,  out  of  pieces  of  the  common  roller. 

Of  lint,  the  patent,  or  apothecary's,  as  it  is  termed,  is  the 
best,  as  it  is  soft  and  easily  adapted  to  the  parts  to  which  it  is 
intended  to  be  applied.  Old  linen  or  muslin  also  answers 
sufficiently  well.     Charpie  is  now  seldom  used. 

An  abundance  of  adhesive  plaster,  put  up  in  small  cases, 
should  be  provided.     Collodion  will  not  be  necessary. 

Splints,  of  binders  or  trunk-maker's  board,  and  of  light 
wood,  should  find  a  place  in  every  medical  store,  as  frequent 
occasions  occur  for  their  use.  In  fractures  of  the  lower 
extremity  special  apparatus  may  be  required,  which,  however, 
as  it  is  cumbrous  and  inconvenient  to  carry,  may  generally  be 
prepared  as  it  is  needed. 

Cushions  are  made  of  muslin,  sewed  in  the  form  of  bags, 
of  variable  size  and  shape,  and  filled  with  cotton,  tow,  sawdust 


MEDICAL   SURGERY.  19 

or  sand.  They  are  designed  to  equalize  and  ward  off  pressure 
in  the  treatment  of  fractures  of  the  lower  extremities. 

Wadding  is  a  most  valuable  article  in  surgical  practice, 
both  for  lining  splints  and  making  pads,  as  well  as  in  the 
treatment  of  burns  and  scalds,  and  cannot  be  dispensed  with. 

Oiled  Silk  is  a  prominent  article  in  the  dressings  of  the 
present  day;  it  preserves  the  heat  and  moisture  of  poultices 
and  of  warm  water-dressings,  at  the  same  time  that  it  protects 
the  bed  and  body-clothes  of  the  patient. 

Oil-doth,  soft  and  smooth,  is  required  in  all  cases  of  sever! 
wounds  and  fractures,  attended  with  much  discharge. 

Air-cuslfions  should  be  put  up  in  considerable  numbers,  as 
their  use  will  be  indispensable  in  all  cases  of  disease  and  injury 
involving  protracted  confinement. 

Bran  and  saw-dust  will  be  found  of  great  value  in  the 
treatment  of  compound  fractures,  ulcers,  gangrene,  and  sup- 
purating wounds,  as  an  easy  support  for  the  injured  limb  and 
a  means  of  excluding  flies. 

Meclical  case-looks  should  be  put  up  along  with  the  other 
articles,  for  the  accurate  registration  of  the  names  of  the  sick 
and  wounded,  the  nature  of  their  lesions,,  and  the  results  of 
treatment.  The  medical  officers  should  also  keep  a  faithful 
record  of  the  state  of  the  weather,  the  temperature  of  the  air, 
the  nature  of  the  climate,  the  products  of  the  soil,  and  the 
botany  of  the  country  through  which  they  or  in  which  they 
sojourn,  together  with  such  matters  as  may  be  of  professional 
or  scientific  interest.  The  knowledge  thus  acquired  should 
be  disseminated  after  their  return  for  the  benefit  of  their  pro- 
fessional brethren. 

Finally,  in  order  to  complete  hospital  equipments,  well- 
trained  nurses  should  be  provided ;  for  good  nursing  is  indis- 
pensable in  every  case  of  serious  disease,  whatever  may  be  its 
character.  The  importance  of  this  subject,  however,  is  now  so 
well  appreciated  as  not  to  require  any  special  comments  here. 

The  question  as  to  whether  this  duty  should  be  performed 
by  men  or  women  is  of  no  material  consequence,  provided  it 


20  MEDICAL   SURGERY. 

be  well  done.  The  eligibility  of  women  for  this  task  was 
thoroughly  tested  in  the  Crimea,  through  the  agency  of  that 
noble-hearted  female,  Florence  Nightingale ;  and  hundreds  of 
the  daughters  of  our  land  ha;Ve  already  tendered  their  services 
to  the  government  for  this  object.  No  large  and  well  regu- 
lated hospital  can  get  on  without  some  male  nurses,  and  they 
are  indispensable  in  camp  and  field  practice. 

It  is  not  my  purpose  here  to  point  out  the  qualities  which 
constitute  a  good  female  nurse.  It  will  suffice  to  say  that  she 
snould  be  keenly  alive  to  her  duties,  and  perform  them,  how- 
ever menial  or  distasteful,  with  promptness  and  alacrity.  She 
must  be  tidy  in  her  appearance,  with  a  cheerful  co'untenance, 
light  in  her  step,  noiseless,  tender  and  thoughtful  in  her  man- 
ners, perfect  mistress  of  her  feelings,  healthy,  able  to  bear 
tigue,  and  at  least  twenty-two  years  of  age.  Neither  the 
crinoline  nor  the  silk  dress  must  enter  into  her  wardrobe;  the 
former  is  too  cumbrous,  while  the  latter  by  its  rustling  is  sure 
to  fret  the  patient  and  disturb  his  sleep.  Whispering  and 
walking  in  on  tiptoe,  as  has  been  truly  observed  by  Florence 
Nightingale,  are  an  abomination  in  the  sick  chamber.  Final- 
ly, a  good  nurse  never  fails  to  anticipate  all,  or  nearly  all,  the 
more  important  wants  of  the  sufi'erer. 

Among  other  things  to  be  specially  attended  to  in  nursing, 
is  venfilation.  Persons  visiting  the  sick  miist  at  once  be 
struck  with  the  difference  of  pure  air  in  those  chambers  where 
a  proper  ventilation  exists  and  those  where  the  reverse  is  the 
case.  To  insure  this  the  fresh  air  should  always  be  admitted 
from  a  window  not  open  directly  on  the  bed,  or  causing  the 
patient  to  be  in  a  draught.  Even  in  winter  it  is  highly  proper 
that  fresh  air  should  be  admitted  some  time  during  the  day 
when  there  is  a  good  fire  and  the  patient  well  protected  by 
covering. 

The  pillows,  bedding  and  bed-clothes  should  be  well  aired 
and  often  changed,  as  also  the  flannel,  under-garments,  and 
night-dress.  To  facilitate  this,  it  is  well,  when  the  patient  is 
very  ill  and  unable  to  help  himself,  to  have  the  shirt  open  all 


MEDICAL    SURGERY.  21 

• 
the  way  down  in  front,  and  buttoned  up.  The  patient  often 
escapes  great  suffering  and  annoyance  by  this  simple  method. 
Where  there  is  a  discharge  from  the  sores,  or  when  water- 
dressings  are  applied  to  a  limb,  it  is  advisable  to  place  the  lat- 
ter upon  a  folded  sheet  with  a  thin,  soft  oil-cloth  underneath. 
Great  tenderness  and  cleanliness  should  be  used  in  dressing 
wounds  or  sores.  Old  linen,  muslin  and  lint  should  always  be 
had  in  readiness  for  this  purpose.  A  great  prejudice  exists 
against  the  use  of  muslin,  the  preference  being  generally  given 
to  linen ;  but  the  former  is  really  quite  as  good  as  the  other, 
if  it  is  soft  and  old. 

In  regard  to  the  cleanliness  of  a  sick-room,  it  is  advisable 
to  use  a  mop  occasionally  for  the  removal  of  flue  from  under 
the  bed;  when,  however,  the  patient  is  in  too  critical  a  situa- 
tion for  dampness,  a  few  tea-leaves  scattered  over  the  apart- 
ment will  absorb  the  dust,  and  can  be  quietly  taken  up  with 
a  hand-brush.  A  frequent  change  of  bed  linen  is  very  bene- 
ficial when  practicable,  and  the  clothes  must  always  be  folded 
smoothly  under  the  patient.  Great  cleanliness  should  be  ob- 
served in  all  the  surroundings  of  the  sick-room,  and  particular 
attention  must  be  paid  to  the  glasses  in  which  medicine  is 
given,  in  order  to  render  the  doses  as  palatable  as  possible. 
The  patient  should  be  washed  whenever  able,'  and  his  teeth 
and  hair  well  attended  to.  The  body  seems  infused  with  new 
vigor  after  such  ablutions. 

A  frequent  change  o^  posture  is  immensely  conducive  to  the 
comfort  and  well  being  of  a  sick  person,  if  performed  with  a 
careful  eye  to  his  particular  condition.  Severe  pain,  loss  of 
sleep,  excessive  constitutional  irritation,  and  dreadful  bed-sores 
are  sure  to  follow,  in  all  low  states  of  the  system,  if  this  pre- 
caution be  not  duly  heeded.  No  patient  must  have  his  head 
suddenly  raised,  or  be  permitted  to  lie  high,  when  he  is  ex- 
hausted from  shock,  hemorrhage,  or  sickness.  Many  lives 
have  been  lost  by  this  indiscretion. 

The  apartment  must  be  free  from  noise,  the  light  should 
neither  be  too  freely  admitted  nor  too  much  excluded,  except 


22  MEDICAL    SURGERY. 

♦ 
in  head  and  eye  affections,  and  the  temperature  must  be  regu- 
lated by  the  thermometer,  from  65°  to  68°  of  Fahrenheit  be- 
ing a  proper  average. 

As  the  patient  acquires  strength,  he  may  gradually  sit  up 
in  bed,  propped  up  at  first  by  pillows,  and  afterward  by  a  bed- 
chair. 

His  food  and  drink,  and  also,  at  times,  his  medicine,  must 
be  given  from  a  feeding-cup  during  the  height  of  his  disease, 
and  a  good  general  rule  is  to  administer  them  with  great  regu- 
larity, provided  this  does  not  interfere  too  much  with  his 
repose.  If  he  is  very  weak,  and  sleeps  very  long,  it  will  be  ne- 
cessary to  wake  him  in  order  to  give  him  nourishment ;  but, 
in  general,  sleep  is  more  refreshing  than  food,  and  more  bene- 
ficial than  medicine.  The  bed-pan  and  urinal  of  course  find 
their  appropriate  sphere  under  such  circumstances. 

As  the  appetite  and  strength  increase,  the  patient  is  permit- 
ted to  resume,  though  very  gradually,  his  accustomed  diet,  and 
to  exercise  about  the  room,  if  not  in  the  open  air.  After  se- 
vere accidents  and  protracted  sickness,  a  wise  man  will  not  be- 
stir himself  too  soon  or  too  much,  but  court  the  fickle  goddess 
of  health  with  becomiog  caution. 

Dying  patients  should  be  carefully  screened  from  their 
neighbors,  placed  in  the  easiest  posture,  have  free  access  of 
air,  and  be  not  disturbed  by  noise,  loud  talking,  or  the  pres- 
ence of  persons  not  ^leeded  for  their  comfort.  As  soon  as  the 
mortal  struggle  is  over,  the  body  must  be  removed. 

The  excretions  should  be  removed  as  speedily  as  possible 
from  the  apartment,  and  the  vessels  in  which  they  are  re-* 
ceived  immediately  well  scalded,  the  air  being  at  the  same 
time  perfectly  purified  by  ventilation,  or  ventilation  and  disin- 
fectants. 

Finally,  the  nurse  must  take  care  of  herself.  She  must 
have  rest,  or  she  will  soon  break  down.  If  she  is  obliged  to 
be  up  all  night;  she  should  be  spared  in  the  day. 


MEDICAL   SURGERY.  23 

CHAPTER  y. 
WOUNDS  AND  OTHER  INJURIES. 

The  injuries  inflicted  in  war  are,  in  every  respect,  similar  to 
those  received  in  civil  life.  The  most  common  and  important 
are  fractures,  dislocations,  bruises,  sprains,  burns,  and  the  dif- 
ferent kinds  of  wounds,  as  the  incised,  punctured,  lacerated, 
and  gunshot.  With  the  nature,  diagnosis  and  mode  of  treat- 
ment of  these  lesions,  every  army  surgeon  must,  of  course,  be 
supposed  to  be  familiar ;  and  I  shall  therefore  limit  myself,  in 
the  remarks  which  I  am  about  to  offer  upon  these  subjects,  to 
a  few  practical  hints  respecting  their  management  on  the  field 
of  battle  and  in  the  ambulance. 

Most  of  the  cases  of  fractures  occurring  on  the  field  of  bat- 
tle arc  the  result  of  gunshot  injury,  and  are  frequently,  if  not 
generally,  attended  by  such  an  amount  of  injury  to  the  soft 
parts  and  also  to  the  bone,  as  to  demand  amputation.  The 
bone  is  often  dreadfully  comminuted,  and  consequently  utterly 
unfit  for  preservation.  The  more  simple  fractures,  on  the 
contrary,  readily  admit  of  the  retention  of  the  limb,  without 
risk  to  life. 

In  transporting  persons  affected  with  fractures,  whether 
simple  or  complicated,  the  utmost  care  should  be  used  to  ren- 
der them  as  comfortable  as  possible,  by  placing  the  injured 
limb  in  an  easy  position,  and  applying,  if  need  be,  on  account 
of  the  distance  to  which  they  have  to  be  carried,  or  the  mode 
of  conveyance,  short  side  splints  of  binders'  board,  thin  wood, 
as  a  shingle,  or  junks  of  straw,  gently  confined  by  a  roller. 
For  want  of  due  precaution,  the  danger  to  limb  and  life  may 
be  materially  augmented.  Permanent  dressings  should  heap-, 
plied  at  the  earliest  moment  after  the  patient  reaches  the  hos- 
pital.    If  the  fracture  be  attended   with  splintering  of  the 


24  MEDICAL   SURGERY. 

bone,  all  loose  or  detached  pieces  should  at  once  be  extracted ; 
a  proceeding  which  always  wonderfully  simplifies  the  case,  in- 
asmuch as  it  prevents,  in  a  great  measure,  the  frightful  irrita- 
tion and  suppuration  which  are  sure  to  follow  their  retention. 
When  this  point  has  been  properly  attended  to,  the  parts 
should  be  neatly  brought  together  by  suture,  and  covered  with 
a  compress  wst  with  blood.  As  soon  as  inflammation  arises — 
not  before — water-dressings  are  employed.  A  suitable  open- 
ing, or  bracket,  should  be  made  in  the  apparatus  to  facilitate 
drainage  and  dressing. 

Dislocations,  accidents  by  no  means  common  in  military 
operations,  are  treated  according  to  the  general  rules  of 
practice ;  they  should  be  speedily  reduced,  without  the  aid 
of  chloroform,  if  the  patient  is  faint  or  exhausted;  with 
chloroform,  if  he  is  strong  or  reaction  has  been  fully  estab- 
lished. The  operation  may  generally  be  successfully  per- 
formed by  simple  manipulation;  if,  however,  the  case  is 
obstinate,  pulleys  may  be  necessary,  or  extension  and  counter- 
extension  made  by  judicious  assistants. 

Bruises,  or  contusions,  unless  attended  with  pulpification, 
disorganization,  or  destruction  of  the  tissues,  are  best  treated, 
at  first,  until  the  pain  subsides,  with  tepid  water  impregnated 
with  laudanum  and  sugar  of  lead,  or  some  tepid  spirituous 
lotion,  and  afterward,  especially  if  the  patient  be  strong  and 
robust,  with  cold  water,  or  cold  astringent  fluids.  If  the 
injury  be  deep  seated,  extensive,  and  attended  with  lesion  of 
very  important  structures,  the  case  will  be  a  serious  one, 
liable  to  be  followed  by  the  worst  consequences,  requiring, 
perhaps,  amputation. 

JSpraifis  are  often  accompanied  with  excessive  pain,  and 
even  severe  constitutional  symptoms.  They  should  be  treated 
with  the  free  use  of  anodynes  and  with  warm  water-dress- 
ings medicated  with  laudanum,  or  laudanum  and  lead.  The 
joint  must  be  elevated  and  kept  at  rest  in  an  easy  posi- 
tion. Leeches  may  be  applied,  if  they  can  be  obtained; 
otherwise,  if  plethora  exist,  blood  may  be  taken  from  the  arm. 


MILITARY   SURGERY.  25 

Bjrand-by  sorbefacicnt  liniments  and  friction  come  in  play. 
Passive  motion  should  not  be  instituted  too  soon. 

Among  the  accidents  of  war  are  hums,  and,  occasionally, 
also  scalds.  The  former  may  be  produced  by  ordinary  fire  or 
by  the  explosion  of  gunpowder,  either  casual  or  from  the 
blowing  up  of  redoubts,  bridges,  houses,  or  arsenals,  and  vary 
from  the  trivial  to  the  most  serious  lesions,  involving  a  great 
extent  of  surface  or  of  tissue,  and  liable  to  be  followed  by  the 
worst  consequences.  Such  injuries  always  require  prompt 
attention ;  for,  apart  from  the  excessive  pain  and  collapse 
which  so  often  accompany  them,  the  longer  they  remain 
uncared  for  the  more  likely  will  they  be  to  end  badly. 

Various  remedies  have  been  proposed  for  these  injuries.  I 
have  myself  always  found  white-lead  paint,  such  as  that  em- 
ployed in  the  arts,  mixed  with  li»seed  oil  to  the  consistence  of 
very  thick  cream,  and  applied  so  as  to  form  a  complete  coat- 
ing, the  most  soothing  and  efficient  means.  The  dressing  is 
fiiaished  by  enveloping  the  parts  in  wadding,  confined  by  a 
moderately  tight  roller.  It  should  not  be  removed,  unless 
there  is  much  discharge  or  swelling,  for  several  days.  If  vesi- 
cles exist,  they  should  previously  be  opened  with  a  needle  or 
the  point  of  a  bistoury.  A  liniment  or  ointment  of  glycerin, 
lard  or  simple  cerate,  and  subnitrate  of  bismuth,  as  suggested 
by  my  friend.  Professor  T.  G.  Richardson,  of  New  Orleans,  is 
also  an  excellent  remedy,  and  may  be  used  in  the  same  man- 
ner as  the  white  lead  paint.  In  the  milder  cases,  carded 
cotton,  cold  water,  and  alcohol,  water  and  laudanum,  generally 
afi'ord  prompt  relief.  Amputation  will  be  necessary  when 
there^^s  extensive  destruction  of  the  muscles,  bones  or  joints. 
Reaction  must  be  promoted  by  the  cautious  use  of  stimulants ; 
while  pain  is  allayed  by  morphia  or  laudanum  given  with 
more  than  ordinary  circumspection,  lest  it  induce  fatal  oppres- 
sion of  the  brain. 

In  burns  from  the  explosion  o^  gunpowder,  particles  of  this 
substance  are  often  buried  in  the  skin,  where,  if  it  be  not 
removed,  they  leave  disfiguring  marks.  The  best  way  to  get 
2  ■ 


26  MILITARY    SURGERY. 

rid  of  them  is  to  pick  out  grain  after  grain  with  the  point  of 
a  narrovv-bladed  bistoury  or  cataract  needle. 

The  subject  of  wounds  is  a  most  important  one  in  regard  to 
field  practice,  as  these  lesions  are  not  only  of  frequent  occur-^ 
rence,  but  present  themselves  in  every  variety  of  form  and 
extent.  Their  gravity  is  influenced  by  numerous  circum- 
stances which  our  space  d(fcs  not  permit  us  to  specify,  but 
which  the  intelligent  reader  can  readily  appreciate.  In  many 
cases  death  is  instantaneous,  owing  to  shock,  or  shock  and 
hemorrhage;  in  others  it  occurs  gradually,  with  or  without 
reaction,  at  a  period  of  several  hours,  or,  it  may  be,  not  under, 
several  days.  Sometimes  men  are  destroyed  by  Shock,  by 
apparently,  the  most  insignificant  wound  or  injury,  owing,  not 
to  want  of  courage,  but  to  some  idiosyncracy. 

The  indications  presented  in  all  wounds,  of  whatever  na- 
ture, are — 1st,  to  relieve  shock;  2dly,  to  arrest  hemorrhage; 
3dly,  to  remove  foreign  matter;  4thly,  to  approximate  and 
retain  the  parts;  and,  5thly,  to  limit  the  resulting  inflam-' 
mation. 

1.  It  is  not  necessary  to  describe  minutely  the  symptoms  of 
shocJcj  as  the  nature  of  the  case  is  sufiiciently  obvious  at  first 
sight,  from  the  excessive  pallor  of  the  countenance,  the  weak- 
ened or  absent  pulse,  the  confused  state  of  the  mind,  the 
nausea,  or  nausea  and  vomiting,  and  the  excessive  bodily 
prostration.  The  case  must  be  treated  promptly :  by  free 
access  of  fresh  air  and  the  use  of  the  fan,  by  loosening  the 
dress  or  the  removal  of  all  sources  of  constriction,  by  dashing 
cold  water  into  the  face  and  upon  the  chest,  by  recumbency  of 
the  head,  and  by  draught  of  cold  water,  or  water  and  ^irits, 
wine  or  hartshorn,  if  the  patient  can  swallow;  aided,  if  the 
case  be  urgent,  by  sinapisms  to  the  region  of  the  heart,  the 
inside  of  thighs  and  the  spine,  and  stimulating  injections,  as 
brandy,  turpentine,  mustard,  or  ammonia,  in  a  few  ounces  of 
water.  No  fluid  must  be  put  into  the  mouth  so  long  as  the 
power  of  deglutition  is  gone,  lest  some  of  it  should  enter  the 
windpipe,  and  so  occasion  suffocation.     Whatever  the  cause  of 


MILITARY   SURGERY.  27 

the  sLock  may  have  been,  let  the  medical  attendant  not  fail  to 
encourage  the  suflferer  by  a  kind  and  soothing  expression, 
which  is  often  of  more  value  in  recalling  animation  than  the 
best  cordials. 

During  an  actual  engagement,  the  liicdical  officers,  as  well 
as  their  servants,  should  carry  in  their  pockets  such  articles  as 
the  wounded  will  be  most  likely  to  need  on  the  field  of  battle, 
as  brandy,  aromatic  spirits  of  hartshotn,  and  morphia,  put  up 
in  suitable  doses. 

2.  The  hemorrhage  may  be  arterial  or  venous,  or  both  arte- 
rial and  venous,  slight  or  profuse,  primary  or  secondary, 
external  or  internal.  The  scarlet  color  and  saltatory  jet  will 
inform  us  when  it  is  arterial;  the  purple  hue  and  steady  flow, 
when  it  is  venous.  When  the  wound  is  severe,  or  involving 
a  large  artery  or  vein,  or  even  middle-sized  vessels,  the  bleed- 
ing may  prove  fatal  in  a  few  minutes,  unless  immediate  assist- 
ance is  rendered.  Hundreds  of  persons  die  on  the  field-  of 
battle  from  this  cause.  They  allow  their  life  current  to  ruff 
out,  as  water  pours  from  a  hydrant,  without  an  attempt  to 
stop  it  by  thrusting  the  finger  in  the  wound,  or  compressing 
the  main  artery  of  the  injured  limb.  They  perish  simply 
from  their  ignorance,  because  the  regimental  surgeon  ha3 
failed  to  give  the  proper  instruction.  It  is  not  necessary  that 
the  common  soldier  should  carry  a  Petit's  tourniquet,  but 
every  one  may  put  into  his  pocket  a  stick  of  wood,  six'inches 
long,  and  a  handkerchief  or  piece  of  roller,  with  a  thick  com- 
press, and  be  advised  how,  where,  and  when  they  are  to  be 
used.  By  casting  the  handkerchief  round  the  limb,  and  plac- 
ing the  compress  over  its  main  artery,  he  can,  by  means  of 
the  stick,  produce  such  an  amount  of  compression  as  to  put  at 
once  an  efi'ectual  stop  to  the  hemorrhage.  This  simple  contri- 
vance, which  has  been  instrumental  in  saving  thousands  of 
lives,  constitutes  what  is  called  the  field  tourniquet.  A  fife, 
drum-stick,  knife  or  ramrod  may  be  used,  if  no  special  piece 
of  wood  is  at  hand. 

The  moat  reliable  means  for  arresting  hemorrhage  perma- 


28  MILITARY   SURGERY. 

nently  is  the  ligature^  of  strong,  delicate,  well-waxed  silk, 
well  applied,  with  one  end  cut  oiF  close  to  the  knot.  Acu- 
pressure is  hardly  a  proper  expedient  upon  the  battle-field, 
or  in  the  ambulance,  especially  when  the  number  of  wounded 
is  considerable.  Th»f  rule  invariably  is  to  tie  a  wounded 
artery  both  above  and  below  the  seat  of  injury,  lest  recurrent 
bleeding  should  arise.  Another  equally  obligatory  precept  is 
to  ligature  the  vessels,  if  practicable,  at  the  place  whence  the 
blood  issues,  by  enlarging,  if  need  be,  the  original  wound. 
The  main  trunk  of  the  artery  should  be  secured  only  when  it 
cannot  be  taken  up  at  the  point  just  mentioned.  Lastly,  it  is 
hardly  requisite  to  add  that  the  operation  should  be  performed, 
with  the  aid  of  the  tourniquet,  as  early  as  possible,  before  the 
supervention  of  inflammation  and  swelling,  which  must  neces- 
sarily obscure  the  parts  and  increase  the  surgeon's  embar- 
rassment, as  well  as  the  patient's  pain  and  risk. 

Venous  hemorrhage  usually  stops  spontaneously,  or  readily 
yields  to  compression,  even  when  a  large  vein  is  implicated. 
The  ligature  should  be  employed  only  in  the  event  of  abso- 
lute necessity,  for  fear  of  inducing  undue  inflammation. 

Torsion  is  unworthy  of  confidence  in  field  practice,  and  the 
same  is  true  of  styptics,  except  when  the  hemorrhage  is  capil- 
lary, or  the  blood  oozes  from  numerous  points.  The  most 
approved  articles  of  this  kind  are  Monsel's  salt,  or  the  persul- 
phate of  iron  and  the  perchloride  of  iron ;  the  latter  deserv- 
ing the  preference,  on  account  of  the  superiority  of  its  hemos- 
tatic properties.     Alum  and  lead  are  inferior  styptics. 

Temporary  compression  may  be  made  with  the  tourniquet, 
or  a  compress  and  a  roller.  It  may  be  direct,  as  when  the 
compress  is  applied  to  the  orifice  of  the  bleeding  vessel,  or 
indirect,  as  when  it  is  applied  to  the  trunk  of  the  vessel,  at 
some  distance  from  the  wound. 

Constitutional  treatment  in  hemorrhage  is  of  paramount 
importance.  It  comprises  perfect  tranquility  of  mind  and 
body,  cooling  drinks,  a  mild,  concentrated  nourishing  diet, 
especially  when  there  has  been  excessive  loss  of  blood,  ano- 


MILITARY   SURGERY.  29 

dynes  to  allay  pain,  induce  sleep,  and  allay  tbe  heart's  inordi- 
nate action,  fresh  air,  and  a  properly  regulated  light. 

Internal  hemorrhage  is  more  dangerous  than  external,  be- 
cause it  is  generally  inaccessible.  The  chief  remedies  are 
copious  venesection,  elevated  position,  opium  and  acetate  of 
lead,  cool  air,  and  cool  drinks. 

Exhaustion  from  hemorrhage  should  be  treated  according  to 
the  principles  which  guide  the  practitioner  in  cases  of  severe 
shock.  Opium  should  be  given  freely  as  soon  as  reaction 
begins  to  quiet  the  tremulous  movements  of  the  heart  and 
tranquilize  the  mind.  When  the  bleeding  is  internal,  the  re- 
action should  be  brought  about  gradually,  not  hurriedly,  lest 
we  thus  become  instrumental  in  promoting  or  re-exciting  the 
hemorrhage. 

Secondary  hemorrhage  comes  on  at  a  variable  period,  from 
a  few  hours  to  a  number  of  days ;  it  may  depend  upon  imper- 
fect ligation  of  the  arteries,  ulceration,  softening  or  gangrene 
of  the  coats  of  these  vessels,  or  upon  undue  constriction  of 
the  tissues  by  tight  bandages.  In  some  cases  it  is  venous, 
and  may  then  be  owing  to  inadequate  support  of  the  parts. 
Whatever  the  cause  may  be,  it  should  be  promptly  searched 
out,  and  removed. 

3.  The  third  indication  is  to  remove  all  foreign  matter. 
This  should  be  done  at  once  and  effectually;  with  sponge  and 
water,  pressed  upon  the  parts,  with  finger,  or  finger  and  for- 
ceps. Not  a  particle  of  matter,  not  a  hair,  or  the  smallest 
clot  of  blood  must  be  left  behind,  otherwise  it  will  be  sure  to 
produce  and  keep  up  irritation. 

4.  As  soon  as  the  bleeding  has  been  checked  and  the  ex- 
traneous matter  cleared  away,  the  edges  of  the  wound  are 
gently  and  evenly  approximated  and  permanently  retained  by 
suture,  and  adhesive  plaster,  aided,  if  necessary,  by  the 
bandage.  The  best  suture,  because  the  least  irritating,  is  that 
made  of  silver  wire;  but  if  this  material  is  not  at  hand, 
strong,  thin,  well-waxed  silk  is  used.  The  adhesive  strips  are 
applied  in  such  a  manner  as  to  admit  of  free  drainage.     The 


30  MILITARY   SURGERY. 

bandage  is  required  chiefly  in  injuries  extending  deeply 
among  the  muscles ;  when  this  is  the  case,  its  use  should  be 
aided  by  compresses  arranged  so  as  to  force  together  the  deep 
partS'oT  the  wound. 

5".  When  the  wound  is  dressed,  the  next  duty  of  the  sur- 
geon is  to  moderate  the  resulting  infiammation.  For  this 
purpose  the  ordinary  antiphlogastic  means  are  employed.  In 
general,  very  little  medicine  will  be  required,  except  a  full 
anodyne,  as  half  a  grain  of  morphia,  immediately  after  the 
patient  has  sufficiently  recovered  from  the  effects  of  his  shock, 
and  perhaps  a  mild  aperient  the  ensuing  morning,  especially 
if  there  be  constipation  with  a  tendency  to  excessive  reaction. 
The  drinks  must  be  cooling,  and  the  diet  light  and  nutritious, 
or  otherwise,  according  to  the  amount  of  depression  and  loss 
of  blood.  In  the  latter  event,  a  rich  diet  and  milk-punch  may 
be  required  from  the  beginning.  A  diaphoretic  draught  will 
be  needed  if  the  skin  is  hot  and  arid,  aided  by  frequent  spong- 
ing of  the  surface  with  cool  or  tepid  water.  General  bleeding 
will  rarely,  if  ever,  be  required;  certainly  not  if  the  injury  is 
at  all  severe,  or  if  there  has  already  been  any  considerable 
waste  of  blood  and  nervous  power. 

Much  trouble  is,  at  times,  experienced  both  in  civil  and 
military  practice,  especially  in  very  hot  weather,  in  preventing 
the  access  of  flies  to  our  dressing.  The  larvas  w^hich  they 
deposit  are  rapidly  developed  into  immense  maggots^  which 
creeping  over  the  wounds  and  sores  of  the  patient,  and  gnaw- 
ing the  parts,  -cause  the  most  horrible  distress.  The  soldiers 
in  Syria,  under  Larrey,  were  greatly  annoyed  by  these  insects, 
and  our  wounded  in  Mexico  also  suffered  not  a  little  from 
them.  The  best  prevention  is  bran,  or  light  saw-dust,  with 
which  the  injured  parts  should  be  carefully  covered.  The  use 
of  cotton  must  be  avoided,  inasmuch  as  it  soon  becomes  hot 
and  wet;  two  circumstances  highly  favorable  to  incubation. 

The  best  local  applications  are  the  water-dressings,  either 
tepid,  cool,  or  cold,  according  to  the  temperament  of  the  pa- 
tient, the  tolerance  of  the  parts,  and  the  season  of  the  year. 


MILITARY   SURGERY.  31 

Union  by  the  first  intention  is,  in  all  the  more  simple  cases,  the 
thing  aimed  at  and  steadily  kept  in  view,  and  hence  the  less 
the  parts  are  encumbered,  moved  or  fretted,  the  more  likely 
sBall  we  be  to  attain  the  object. 

The  medical  attendant  should  have  a  constant  eye  to  the 
condition  of  the  bladder  after  all  severe  injuries,  of  whatever 
character,  as  retention  of  urine  is  an  extremely  common  occur- 
rence, and  should  always  be  promptly  remedied.  Attention 
to  this  point  is  the  more  necessary,  because  the  poor  patient, 
in  his  comatose  or  insensible  condition,  is  frequently  unable 
to  make  known  his  wants. 

Such,  in  a  few  words,  are  the  general  principles  of  treat- 
ment to  be  followed  in  all  wounds;  but  there  are  some  wounds 
which  are  characterized  by  peculiarities,  and  these  peculiarities 
are  of  such  pructical  importance  as  to  require  separate  con- 
sideration. Of  this  nature  are  punctured,  lacerated,  and  gun- 
shot wounds. 

Punctured  icounds  are  inflicted  by  various  kinds  of  weapons, 
as  the  lance,  sabre,  sword  or  bayonet.  In  civil  practice,  they 
are  most  generally  met  with  ns  the  result  of  injuries  inflicted 
by  nails,  needles,  splinters,  fragments  of  bone.  They  often 
extend  into  the  visceral  cavities,  joints,  vessels,  and  nerves; 
and  are  liable  to  be  followed  by  excessive  pain,  erysipelas,  ^nd 
tetanus;  seldom  heal  by  adhesive  action;  and  often  cause  death 
by  shuck  or  hemorrhage.  When  the  vulnerating  body  is 
broken  off"  and  buried,  it  may  be  difficult  to  find  and  extract 
it,  especially  when  small  and  deep  seated.  ^Yhen  this  is  the 
case,  the  wound  must  be  freely  dilated,  an  eye  being  had  to 
the  situation  of  the  more  important  vessels  and  nerves.  In 
other  respects,  the  general  principles  of  treatment  are  similar 
to  those  of  incised  wounds.  Opium  should  be  administered 
largely;  and,  if  much  tension  supervene,  or  matter  form,  free, 
incisions  will  be  necessary. 

In  lacerated  icounds,  the  edges  should  be  tacked  together 
very  gently,  and  large  interspaces  left  for  drainage.  A  small 
portion  will  probably  unite  by  the  first  intention;  the  remain- 


82  MILITARY   SURGERY. 

der  by  the  granulating  process.  Such  wounds  nearly  always 
suppurate  more  or  less  profusely,  and  some  of  the  torn  or 
bruised  tissues  not  unfrequently  perish.  The  same  bad  conse- 
quences are  apt  to  follow  them  as  in  punctured  wounds.  Warm 
water  constitutes  the  best  dressing,  either  alone  or  with  the 
addition  of  a  little  spirits  of  camphor.  Opium  should  be  used 
freely  internally,  and  the  diet  must  be  supporting. 

Gunshot  ivoundSf  in  their  general  character,  partake  of  the 
nature  of  lacerated  and  contused  wounds.  They  are,  of  course, 
the  most  common  and  dangerous  lesions  met  with  in  military 
practice;  often  killing  instantly,  or,  at  all  events,  so  mutilat- 
ing the  patient  as  to  destroy  him  within  a  few  hours  or  days 
after  their  receipt.  The  most  formidable  wounds  of  the  kind 
are  made  by  the  conical  rifle  and  musket  balls  and  by  cannon 
balls,  the  latter  often  carrying  away  the  greater  portion  of  a 
limb,  or  mashing  and  pulpifying  the  muscles  and  viscera  in 
the  most  frightful  and  destructive  manner;  while  the  former 
commit  terrible  ravages  among  the  bones,  breaking  them  into 
numerous  fragments,  each  of  which  may,  in  its  turn,  tear  up 
the  soft  tissues,  in  a  way  perhaps  not  less  mischievous  than  the 
ball  itself.  The  old  round  ball  is  a  much  less  fatal  weapon 
than  the  conical,  which  seldom  becomes  flattened,  and  which 
has^  been  known  to  pass  through  the  body  of  two  men  and 
lodge  in  that  of  a  third  some  distance  off. 

When  a  ball  lodges,  it  makes  generally  only  one  orifice ;  but 
it  should  be  remembered  that  it  may  make  two,  three,  and 
even  four,  and  at  last  bury  itself  more  or  less  deeply.  Should 
the  missile  escape,  there  will  necessarily  be  two  openings;  or, 
if  it  meet  a  sharp  bone  and  be  thereby  divided  or  cut  in  pieces, 
as  sometimes  happen,  there  may  be  even  three.  The  orifice 
of  entrance  and  the  orifice  of  exit  differ  in  their  appearances. 
The  first  is  small,  round,  and  often  a  little  discolored  from  the 
explosion  of  the  powder;  the  other,  on  the  contrary,  is  com- 
paratively large,  slit-like,  everted,  and  free  from  color.-  These 
differences,  however,  are  frequently  very  trifling,  particularly 
if  the  ball  be  projected  with  great  velocity  and  it  do  not  en- 


MILIT/RY  SURGERY.  83 

counter  any  bone.  The  opening  of  entrance  made  by  the 
round  ball  is  often  a  little  depressed  or  inverted,  but  such  an 
appearance  is  extremely  uncommon  in  wounds  made  by  the 
conical  ball. 

It  is  often  a  matter  of  great  importance  to  determine,  when 
two  openings  exist  in  a  limb,  whether  they  have  been  made 
by  one  ball,  which  has  passed  out,  or  by  two  balls,  which  are 
retained.  The  question  is  of  grave  importance,  both  in  a 
practical  anci  in  a  medico-legal  point  of  view;  but  its  solution 
is,  unfortunately,  not  always  possible.  Sometimes  the  open- 
ings of  entrance  and  exit  are  materially  modified  by  the  intro- 
duction but  non-escape  of  a  foreign  body,  as  a  piece  of  breast- 
plate, belt,  or  buckle,  along  with  the  ball,  which  alone  passes 
out,  or  by  the  flattening  of  a  ball  against  a  bone,  or  its  division 
by  a  bone  into  several  fragments,  each  of  which  may  afterward 
produce  a  separate  orifice.  Generally  speaking,  the  missile,  at 
the  place  of  entrance,  carries  away  a  piece  of  skin,  and  rends 
the  skin  where  it  escapes,  the  former  being  often  found  in  the 
wound. 

Bullets  sometimes  glance,  bruising  the  skin,  but  not  pene- 
trating it;  at  other  times  they  efi"ect  an  entrance,  but,  instead 
of  passing  on  in  a  straight  line,  are  deflected,  coursing,  per- 
haps, partially  round  the  head,  chest,  or  abdomen,  or  round  a 
limb.  Such  results  are  most  commonly  caused  by  a  partially 
spent  bullet  coming  in  contact  with  bones,  aponeuroses,  and 
tendons;  and  the  round  is  more  frequently  served  in  this  way 
than  the  conical. 

Gunshot  wounds  bleed  profusely  only  when  a  tolerably  large 
artery  has  been  injured,  and  in  this  event  they  may  speedily 
prove  fatal.  During  the  Crimean  war,  however,  many  cases 
occurred  in  which  there  was  no  immediate  hemorrhage,  im- 
periling life,  notwithstanding  the  limbs,  lower  as  well  as  upper, 
were  left  hanging  merely  by  the  integuments.  Under  such 
circumstances,  intermediary  hemorrhage,  as  it  is  termed,  is  apt 
to  sho\«h  itself  as  soon  as  reaction  takes  place;  generally  within 
a  few  hours  after  the  accident. 


34  MILITARY  SURGERT. 

The  pain  is  of  a  dull,  burning,  smarting,  or  aching  character, 
and  the  patient  is  pale,  weak,  tremulous,  nauseated,  and  de* 
spondent,  often  in  a  degree  far  beyond  what  might  be  expected 
from  the  apparent  violence  of  the  injury,  and  that,  too,  'per- 
haps, when  the  individual  is  of  the  most  undaunted  courage 
and  self-possession  in  the  heat  of  battle.  At  other  times,  a 
man  may  have  a  limb  torn  oflP,  or  be  injured  in  some  vital  organ, 
and  yet  hardly  experience  any  shock  whatever;  nay,  perhaps 
be  scarcely  conscious  that  he  is  seriously  hurt.  The  pain  and 
prostration  are  always  greater,  other  things  being  equal,  when 
a  bone  has  been  crushed  or  a  large  joint  laid  open,  than  when 
there  is  a  mere  flesh  wound. 

The  gravity  of  gunshot  wounds  of  the  joints  has  been  re- 
cognized by  all  practitioners,  both  military  and  civil,  from 
time  immemorial.  The  principal  circumstances  of  the  prog- 
nosis are  the  size  and  complexity  of  the  articulation,  the  extent 
of  the  injury,  and  the  state  of  the  system.  A  gunshot  wound 
of  a  ginglymoid  joint  is,  in  general,  a  more  dangerous  affair 
than  a  similar  one  of  a  ball-and-socket  joint.  The  structures 
around  the  articulation  often  suffer  severely,  thus  adding 
greatly  to  the  risk  of  limb  and  life.  Of  65  cases  of  gunshot 
wounds  of  different  joints,  related  by  Alcock,  33  recovered; 
but  of  these  21  lost  the  limb.  Of  the  32  that  died  no  opera- 
tion was  performed  upon  18. 

Gunshot  wounds  of  the  smaller  joints,  even  those  of  the 
ankle,  often  do  very  well,  although  they  always  require  long 
and  careful  treatment.  Lesions  of  this  kind,  involving  the 
shoulder,  are  frequently  amenable  to  ordinary  means.  If  the 
ball  lodges  in  the  head  of  the  humerus,  it  must  be  extracted 
without  delay,  its  retention  being  sure  to  excite  violent  inflam- 
mation in  the  soft  parts,  and  caries  or  necrosis  in  the  bonp, 
ultimately  necessitating  amputation,  if  not*causift^  death. 

Gunshot  wounds  of  the  knee-joint  are  among  the  most  dan- 
gerous of  accidents,  and  no  attempt  should  be  made  to  save  the 
limb  when  the  injury  is  at  all  extensiye,  especially  if  it  in- 
volves fracture  of  the  head  of  the  tibia  or  condyles  of  the 


MILITARY   SURGERT.  85 

femur.  Even  extensive  laceration  of  the  ligament  of  the  pa- 
tella should,  I  think,  as  a  general  rule,  be  regarded  as  a  suffi- 
cient cause  for  amputation.  In  1854,  Macleod  saw  upwards 
of  forty  cases  of  gunshot  wounds  of  the  knee  in  the  French 
hospitals  in  the  Crimea,  and  all,  except  one,  in  which  an  attempt 
was  made  to  save  the  limb,  proved  fatal.  Of  nine  cases  which 
occurred  in  India,  not  one  was  saved.  Guthrie  never  saw  a 
patient  recover  from  a  gunshot  wound  of  the  knee-joint;  and 
Esmarch,  who  served  in  the  Schleswig-Holstein  wars,  expressly 
declares  that  all  lesions  of  this  kind  demand  immediate  ampu- 
tation of  the  thigh. 

When,  in  bad  cases  of  these  articular  injuries,  an  attempt 
is  made  to  save  the  limb,  the  patient  often  perishes  within  the 
first  three  or  four  days,  from  the  conjoined  effects  of  shock, 
hemorrhage,  and  traumatic  fever.  If  he  survives  for  any 
length  of  time,  large  abscesses  are  apt  to  form  in  and  around 
the  joint,  the  matter  burrowing  extensively  among  the  mus- 
cles, and  causing  detachment  of  the  periosteum  with  caries 
and  necrosis  of  the  bones. 

Muscles,  badly  injured  by  bullets,  generally  suppurate,  and 
are  very  apt  to  become  permanently  useless.  Special  paiwi 
should,  therefore,  be  taken  to  counteract  this  tendency  during 
the  cure.  Large  shot  and  other  foreign  bodies  sometimes  lodge 
among  these  structures,  where  their  presence  may  remain  for  a 
long  time  unsuspected. 

Cannon  balls  often  do  immense  mischief  by  striking  the 
surface  of  the  body  obliquely,  pulpifying  the  soft  structures, 
crushing  the  bones,  lacerating  the  large  vessels  and  nerves,  and 
tearing  open  the  joints,  without,  perhaps,  materially  injuring 
the  skin. 

A  very  terrible  form  of  contusion  is  often  inflicted  upon  the 
upper  extremity  of  artillerymen  by  the  premature  explosion  of 
the  gun,  while  in  the  act  of  loading,  causing  excessive  commo- 
tion of  the  entire  limb,  laceration  of  the  soft  parts,  and  most 
extensive  infiltration  of  blood,  accompanied,  in  many  cases,  by 
comminuted  fracture,  and  penetration  of  the  wrist  and  elbow 


86  MILITARY  SURGERY.- 

joints.  The  constitutional  shock  is  frequently  great.  If  an 
attempt  be  made  to  save  the  parts,  diffusive  suppuration,  and 
more  or  less  gangrene,  will  be  sure  to  follow,  bringing  life  into 
imminent  jeopardy.  An  attempt  in  such  a  case  to  save  the 
limb  would  be  worse  than  useless,  if,  indeed,  not  criminal; 
amputation  must  be  promptly  performed,  and  th^t  at  a  con- 
siderable distance  above  the  apparent  seat  of  the  injury,  other- 
wise mortification  might  seize  upon  the  stump, ,  . 

In  the  treatment  of  this  class  of  injuries,  the  first  thing  to 
be  done,  after  arresting  the  hemorrhage  and  relieving  shock,  is 
to  extract  the  ball  and  any  other  foreign  substance  that  may 
have  entered  along  with  it,  the  next  being  to  guard  against 
inflammation  and  other  bad  consequences. 

In  order  to  ascertain  where  the  ball  is,  the  limb  should  be 
placed  as  nearly  as  possible  in  the  position  it  was  supposed  to 
.have  been  at  the  moment  of  the  accident.  A  long,  stout, 
flexible,  blunt-pointed  probe,  or  a  straight  silver  catheter,  is 
then  passed  along  the  track  and  gently  moved  along  until  it 
strikes  the  ball.  In  many  cases  the  best  probe  is  the  surgeon's 
finger.  Valuable  information  may  often  be  obtained  by  the 
process  of  pinching  or  digital  compression,  the  ends  of  the  fin- 
gers being  firmly  and  regularly  pressed  against  the  wounded 
structures,  bones  as  well  as  muscles,  tendons,  and  aponeuroses. 
Occasionally,  again,  as  when  a  ball  is  lodged  in  an  eitremity, 
its  presence  is  easily  detected  by  the  patient,  who  may  make 
such  an  examination  as  he  lies  in  bed. 

The  situation  of  the  foreign  body  having  been  ascertained, 
the  bullet-forceps  take  the  place  of  the  probe,  the  blades, 
which  should  be  long  and  slender,  being  closed  until  they 
come  in  contact  with  the  ball,  when  they  are  expanded  so  as 
to  grasp  it,  care  being  taken  not  to  include  any  of  the  soft 
tissues.  If  there  be  any  loose  or  detached  splinters  of  bone, 
wadding,  or  other  foreign  material,  it  should  now  also  be  re- 
moved; it  being  constantly  borne  in  mind  that,  while  a  ball 
may  occasionally  become  encysted,  and  is  at  all  times,  if 
smooth,   a  comparatively  harmless   tenant,   such   substances 


MILITARY   SURGERY.  87 

always  keep  up  irritation,  and  should,  therefore,  if  possible, 
be  got  rid  of  without  delay. 

Although  preference  is  commonly  given  to  the  bullet-for- 
ceps, properly  so  called,  as  an  extractor,  the  polypus  and 
dressing-forceps,  generally  answer  quite  as  well,  especially  the 
former,  the  latter  being  adapted  only  to  cases  where  the  for- 
eign body  is  situated  a  short  distance  below  the  surface,  or 
where  the  wound  is  of  unusual  dimensions,  admitting  of  the 
free  play  of  the  instrument. 

During  the  extraction,  the  parts  should  be  properly  sup- 
ported, and  if  the  wound  is  not  large  enough  for  the  expan- 
sion of  the  instrument,  it  must  be  suitably  enlarged.  "When 
the  ball  is  lodged  a  short  distance  from  the  skin,  it  may  often 
be  readily  reached  by  a  counter-opening. 

When  a  bullet  is  embedded  in  a  bone,  as  in  the  head  of  the 
tibia,  or  in  the  condyles  of  the  femur,  and  the  parts  are  not 
so  much  injured  as  to  demand  amputation,  extraction  may  be 
effected  with  the  aid  of  the  trephine  and  elevator.  Sometimes 
a  bullet-worm,  as  it  is  termed,  an  instrument  similar  to  that 
used  in  drawing  a  ball  from  a  gun,  will  be  very  convenient  for 
its  removal. 

The  operation  being  completed,  the  parts  are  placed  in  an 
easy,  elevated  position,  and  enveloped  in  tepid,  cool  or  cold 
water-dressings,  as  may  be  most  agreeable  to  them  and  to  the 
system.  The  best  plan,  almost  always,  is  to  leave  the  opening 
or  openings,  made  by  the  ball,  free,  to  favor  drainage  and 
prevent  pain  and  tension.  If  the  track  be  very  narrow,  it 
may  heal  by  the  first  intention,  but  in  general  it  will  suppu- 
rate, and  portions  of  tissue  may  even  mortify.  Erysipelas, 
pyemia,  and  secondary  hemorrhage  are  some  of  the  bad  con- 
sequences after  gunshot  injuries,  the  latter  usually  coming  on 
between  the  fifth  and  ninth  day^  the  period  of  the  separation 
of  the  sloughs. 


MILITARY  SURGERY. 


CHAPTER  VI. 
AMPUTATIONS  AND  RESECTIONS. 

In  endeavoring  to  decide  so  important  a  question  as  tho 
loss  of  a  limb,  various  circumstances  are  to  be  considered,  as 
the  age,  habits  and  previous  health  of  the  patient,  the  kinds 
of  injury,  and  the  number,  nature,  and  importance  of  the  tis- 
sues involved.  In  military  practice,  amputation  must  often 
be  performed  in  cases  where  in  civil  practice  it  might  be 
avoided. 

It  may  be  assumed,  as  a  rule,  that  young  adults  bear  up 
under  severe  accidents  and  operations,  other  things  being 
equal,  much  better  than  children  and  elderly  subjects;  the 
strong  than  the  feeble;  the  temperate  than  the  intemperate; 
the  residents  of  the  country  than  the  inhabitants  of  the 
crowded  city. 

The  following  circumstances  may  be  enumerated  as  justify- 
ing, if  not  imperatively  demanding,  amputation  in  cases  of 
wounds,  whatever  may  be  their  nature  : 

1st.  When  a  limb  has  been  struck  by  a  cannon  ball  or  run 
over  by  a  railroad  car,  fracturing  the  bones,  and  tearing  open 
the  soft  parts,  amputation  should,  as  a  general  rule,  be  per- 
formed, even  when  the  injury  done  to  the  skin  and  vessels  is 
apparently  very  slight,  experience  having  shown  that  such 
accidents  seldom  do  well,  if  an  attempt  is  made  to  save  the 
limb,  the  patient  soon  dying  of  gangrene,  pyemia,  or  typhoid 
irritation.  The  danger  of  an  unfavorable  termination  in  such 
a  case  is  always  greater  when  the  lesion  aflfects  the  lower  ex- 
tremity than  when  it  involves  the  superior. 

2d.  No  attempt  should  be  made  to  save  a  limb  when,  in 
addition  to  serious  injury  done  to  the  integuments,  muscles  or 
bones,  its  principal  artery,  vein  or  nerve  has  been  extensively 


MILITARY  SURGERY.  39 

lacerated,  or  violently  contused,  as  the  result  will  be  likely  to 
be  gangrene,  followed  by  death. 

3d.  A  lacerated  or  gunshot  wound  penetrating  a  large  joint, 
as  that  of  the  knee  or  ankle,  and  accompanied  by  comminu- 
ted fracture,  or  extensive  laceration  of  the  ligaments  of  the 
articulation,  will,  if  left  to  itself,  be  very  prone  to  terminate 
in  mortification,  and  is  therefqfc  a  proper  case  for  early  am- 
putation. 

4th.  Gunshot  wounds  attended  with  severe  comminution  of 
the  bones,  the  fragments  being  sent  widely  around  among  the 
soft  parts,  laceratiag  and  bruising  them  severely,  generally 
require  amputation,  especially  in  naval  and   military  practice. 

5th.  Extensive  laceration,  contusion,  and  stripping  ofi"  of 
the  integuments,  conjoined  with  fracturt,  dislocation,  or  com- 
pression and  pulpiOcation  of  the  muscles,  will,  in  general,  be 
a  proper  cause  for  the  removal  of  a  limb.* 

Amputation  is  not  to  be  performed,  in  any  case,  until  suffi- 
cient reaction  has  taken  place  to  enable  the  patient  to  bear 
the  additional  shock  and  loss  of  blood.  As  long  as  he  is  dead- 
ly pale,  the  pulse  small  and  thready,  the  surface  cold,  and  the 
thirst,  restlessness,  and  jactitation  excessive,  it  is  obvious  that 
recourse  to  the  knife  must  be  wholly  out  of  the  question. 
The  proper  treatment  is  recumbency,  with  mild  stimulants, 
sinapisms  to  the  extremities,  and  other  means  calculated  to 
re-excite  the  action  of  the  heart  and  brain.  Power  being  re- 
stored, the  operation,  if  deemed  necessary,  is  proceeded  with, 
due  regard  being  had  to  the  prevention  of  shock  and  hemor- 
rhage, the  two  things  now  mainly  to  be  dreaded.   . 

One  of  the  great  obstacles  about  immediate  amputation  is 
the  difficulty  which  the  surgeon  so  often  experiences  in  res- 
pect to  the  cases  demanding  tli,e  operation,  and  the  uncertainty 
that  none  of  the  internal  organs  have  sustained  fatal  injury; 
a  circumstance  which  would,  of  course,  contra-indicate  the 
propriety  of  such  interference. 

•  Gross'  Surgery,  vol.  i.  p.  395. 


40  MILITARY  SURaiRY. 

Cases  occur,  although  rarely,  where,  notwithstanding  the 
most  violent  injury,  or  perhaps,  even  the  loss  of  a  limb,  there 
is  hardly  any  appreciable  shock,  and,  in  such  an  event,  the 
operation  should  be  performed  on  the  spot. 

The  results  of  the  military  surgery  in  the  Crimea  show  that 
the  success  of  amputations  was  very  fair  when  performed  early, 
but  most  unfortunate  when  they  were  put  off  any  length  of 
time.  This  was  the  case,  it  would  seem,  both  in  the  English 
and  French  armies. 

Should  amputation  ever  be  performed  in  spreading  gan- 
grene ?  The  answer  to  this  question  must  depend  upon  cir- 
cumstances. We  may  give  our  sanction  when  the  disease, 
although  rapid,  is  still  limited,  and  when  the  patient,  compar- 
atively stout  and  robust,  has  a  good  pulse,  with  no  serious 
lesion  of  a  vital  orgar)  and  no  despair  of  his  recovery,  but  a 
cheerful,  buoyant  mind,  hopeful  of  a.  favorable  issue.  No  op- 
eration is  to  be  done  when  the  reverse  is  the  case ;  if  it  be,  the 
patient  will  either  perish  on  the  table,  from  shock  and  hem- 
orrhage, or  from  a  recurrence  of  mortification  in  the  stump. 

Lacerated,  contused  and  gunshot  wounds  are  often  of  so 
frightful  a  nature  as  to  render  it  perfectly  certain,  even  at  a 
glance,  that  the  limb  will  be  obliged  to  be  sacrificed  in  order 
that  a  better  chance  may  be  afi'orded  for  preserving  the  pa- 
tient's life.  At  other  times,  the  injury,  although  severe,  may 
yet,  apparently,  not  be  so  desperate  as  to  preclude,  in  the 
opinion  of  the  practitioner,  the  possibility  of  saving  the  parts, 
or,  at  all  events,  the  propriety  of  making  an  attempt  to  that 
effect.  The  cases  which  may  reasonably  require  and  those 
which  may  not  require  interference  with  the  knife,  are  not 
always  so  clearly  and  distinctly  defined  as  not  to  give  rise,  in 
very  many  instances,  to  the  most  serious  and  unpleasant  ap- 
prehension, lest  we  should  be  guilty,  on  the  one  hand,  of  the 
sin  of  commission,  and,  on  the  other,  of  that  of  omission ;  or, 
in  other,  and  more  comprehensive  terms,  that  while  the  sur- 
geon endeavors  to  avoid  Scylla,  he  may  not  unwittingly  run 
into  Chary bdis,  mutilating  a  limb  that  might  have  been  save4; 


MILITARY  SURGERY.  41 

• 
and  endangering  life  by  the  retention  of  one  that  should  have 

been_  promptly  amputated.  It  is  not  every  man,  however 
large  his  skill  and  experience,  that  is  always  able  to  satisfy 
himself,  even  after  the  most  profound  deliberation,  what  line 
of  conduct  should  be  pursued  in  these  trying  circumstances ; 
hence  the  safest  plan  for  him  generally  is  to  procure  the  best 
counsel  that  the  emergencies  of  the  case  may  admit  of.  But 
in  doing  this,  he  must  be  careful  to  guard  against  procrastina- 
tion :  the  case  must  be  met  promptly  and  courageously  ;  delay 
even  of  a  few  hours  may  be  fatal,  or  at  all  events,  place  limb 
and  life  in  imminent  jeopardy.  Above  all,  let  proper  caution 
be  used  if  the  patient  is  obliged  to  be  transported  to  some 
hospital,  or  to  a  distant  home,  that  he  may  not  be  subjected 
to  unnecessary  pain,  exposed  to  loss  of  blood,  or  carried  in  a 
position  incompatible  with  his  exhausted  condition.  Vast 
injury  is  often  done  in  this  way,  by  ignorant  persons  having 
charge  of  the  case,  and  occasionally,  even  by  practitioners 
"whose  education  and  common  sense  should  be  a  sufl5cient 
guarantee  against  such  conduct. 

Little  need  be  said  here  about  the  methods  of  amputation. 
In  cases  of  emergency,  where  time  is  precious,  and  the  number 
of  surgeons  inadequate,  the  flap  operation  deserves,  in  my 
opinion,  a  decided  preference  over  the  circular,  and,  in  fact, 
every  other.  The  rapidity  with  which  it  may  be  executed, 
the  abundant  covering  which  it  aflfords  for  the  bone,  and  the 
facility  with  which  the  parts  unite,  are  qualities  which-  strongly 
recommend  it  to  the  judgment  of  the  military  surgeon.  The 
flaps  should  be  long  and  well  shaped,  and  care  taken  to  cut 
off"  the  larger  nerves  on  a  level  with  the  bone,  in  order  to 
guard  against  the  occurrence  of  neuralgia  after  the  wound  is 
healed.  Whatever  method  be  adopted,  a  long  stump  should 
be  aimed  at,  that  it  may  aff"ord  a  good  leverage  for  the  artifi- 
cial substitute.  No  blood  should  be  lost  during  or  after  the 
operation,  and  hence  the  main  artery  of  the  limb  should 
always  be  thoroughly  compressed  by  a  tourniquet,  not  by  tho 


9 

42  MILITARY   SURGERY. 

ficgers  of  assistants,  who  are  seldom,  if  ever,  trustworthy  on 
such  occasions. 

Anaesthetics  should  be  given  only  in  the  event  of  thorough 
reaction ;  so  long  as  the  vital  powers  are  depressed  and  the 
mind  is  bewildered  by  shock,  or  loss  of  blood,  their  adminis- 
tration will  hardly  be  safe,  unless  the  greatest  vigilance  be 
employed,  and  this  is  not  always  possible  on  the  field  of  battle, 
or  even  in  the  hospital.  Moreover,  it  is  astonishing  what 
little  suffering  the  patient  generally  experiences,  when  in  this 
condition,  even  from  a  severe  wound  or  operation. 

In  the  war  in  the  Crimea,  the  British  used  chloroform 
almost  universally  in  their  operations;  the  French  also  exhib- 
ited it  very  e'xtensively,  and  Baudens,  one  of  their  leading 
military  surgical  authorities,  declares  that  they  did  not  meet 
with  one  fatal  accident  from  it,  although  it  was  given  by 
them,  during  the  Eastern  campaign,  thirty  thousand  times  at 
least.  The  administration  of  chloroform  is  stated  by  Macleod 
to  have  contributed  immensely  to  the  success  of  primary  am- 
putations. 

The  dressings  should  be  applied  according  to  the  principles 
laid  down  under  the  head  of  wounds.  The  sutures,  made 
with  silver  wire  or  fine  silk,  should  not  be  too  numerous,  and 
the  adhesive  strips  must  be  so  arranged  as  to  admit  of  thor- 
ough drainage.  A  bandage  should  be  applied  from  above 
downward,  to  control  muscular  action  and  afford  support  to 
the  vessels;  the  stump  rest  upon  a  pillow  covered  with  oil- 
cloth, and  the  water-dressing  be  used  if  there  is  danger  of 
overaction.  Pain  and  spasm  are  allayed  by  anodynes;  trau- 
matic fever,  by  mild  diaphoretics.  Copious  purging  is  avoided ; 
the  drink  is  cooling;  and  the  diet  must  be  in  strict  conform- 
ity with  the  condition  of  tho  patient's  system.  The  first 
dressings  are  removed  about  the  end  of  the  third  day ;  after 
that  once  or  even  twice  a  day,  according  to  the  nature  and 
quantity  of  the  discharges,  accumulation  and  bagging  being 
faithfully  guarded  against. 

The  following  statistics  of  amputations,  both  in  the  conti- 


MILITARY   SURGERY.  43 

nuity  of  the  limbs  and  of  the  articulations,  possess  peculiar 
interest  for  the  military  surgeon.  They  are  derived  chiefly 
from  a  review  which  I  published  of  Mr.  Macleod's  "Notes  of 
the  Surgery  in  the  Crimea,"  in  the  North  American  Medico- 
Cbirurgical  Review  for  January,  1860. 

The  number  of  cases  given  by  Macleod  is  732,  with  a  mor- 
tality of  201.  Of  these,  654  were  primary,  with  165  deaths, 
or  26-22  per  cent.;  and  78  secondary,  with  36  deaths,  or  m 
the  ratio  of  46  1.  The  mortality  of  the  greater  amputations 
—as  those  of  the  shoiilder,  arm  and  forearm,  and  the  hip, 
thigh,  knee  and  leg — was  39  8  per  cent,  for  the  primary  ope- 
rations, and  60  per  cent,  for  the  secondary.  " 

The  increase  of  mortality  from  ampututions  as  we  approach 
the  trunk,  has  long  been  familiar  to  surgeons,  and  the  results 
in  the  Crimea  have  not  changed  our  previous  knowledge. 
Thus  the  ratio  of  mortality  of  amputations  of  the  fingers  was 
0-5;  of  the  forearm  and  wrist,  1-8;  of  the  arm,  229;  of  the 
shoulder,  272;  of  the  tarsus,  142;  of  the  ankle-joint,  222; 
of  the  leg,  30-3;  of  the  knee-joint,  500;  of  the  thigh,  in  its 
lower  third,  50  0,  at  its  middle,  55  3,  at  the  upper  part,  86  8, 
and  at  the  hip,  1000.  The  limb  was  removed  at  the  latter 
joint  in  10  cases,  all  of  which  rapidly  proved  fatal.  The 
French  had  13  cases,  primary  and  secondary,  with  no  better 
luck. 

Legouest  has  published  a  table  of  most  of  the  recorded  cases 
of  amputation  at  the  hip-joinf,  for  gunshot  wounds.  Of  these 
30  were  primary  and  all  ended  fatally;  of  11  intermediate,  or 
early  secondary,  3  recovered ;  and  of  3  remote,  1  reotvered. 
"Thus,"  says  Macleod,  "if  we  sum  up  the  whole,  we  have  4 
recoveries  in  44  cases,  or  a  mortality  of  90  9  percent."  Some 
of  the  primary  cases  died  on  the  table ;  and  all  the  rest,  ex- 
cept two,  before  the  tenth  day.  In  the  Schleswig-Holsteia 
war,  amputation  at  the  hip  joint  was  performed  seven  times, 
with  one  cure.  Mr.  Sands  Cox,  recording  the  experience  of 
civil  and  military  hospitals  up  to  1846,  gives  84  cases,  most 
of  them  for  injury,  with  26  recoveries.     Dr.  Stephen  Smith, 


44  MILITARY   SURGERY. 

of  New  York,  has  published  tables  of  98  cases  showing  a  ratio 
of  mortality  of  one  in  2  2-3.  In  62  of  these  cases,  the  ope- 
ration was  performed  in  30  for  injury,  with  a  mortality  of 
60  per  cent. 

Amputation  in  the  upper  third  of  the  thigh  was  performed 
39  times,  with  a  fatal  result  in  34.  Of  these  cases  only  one 
was  secondary,  and  that  perished.  Amputation  of  the  middle 
third  of  the  limb  was  performed  in  65  cases,  of  which  38 
died.  Of  these  cases  56  were  primary,  with.  31  deaths,  giving 
thus  a  mortality  of  63-3  per  cent.;  9  cases  were  operated  upon 
at  a  later  period,  and  of  these,  7  died,  or  77-7  per  cent.  Am- 
putatioif  of  the  lower  third  of  the  thigh  was  performed  60 
times,  46  being  primary,  with  a  mortality  of  50  per  cent.,  and 
14  secondary,  with  a  mortality  of  71-4  per  cent. 

Amputation  at  the  hnee  was  performed  primarily  in  6  cases, 
of  which  3  died,  and  once  secondarily,  with  a  fatal  result. 
Chelius  refers  to  37  cases  of  amputation  of  the  knee,  collected 
by  Jseger,  of  which  22  were  favorable ;  and  of  18  cases  re- 
corded by  Dr.  Markoe,  of  New  York,  as  having  occurred  in 
the  practice  of  American  surgeons,  13  got  well.  These  cases 
added  together,  afford  an  aggregate  of  61,  with  a  mortality  of 
21,  or  34.4  per  cent. 

The  leg  was  amputated  101  times,  with  86  deaths,  or  a 
mortality  of  35*6  per  cent.  Of  these  cases  89  were  primary, 
with  28  deaths,  and  12  secondary,  with  8  deaths. 

Amputation  at  the  ankle-joint  was  performed  in  12  cases, 
death  following  in  2.  Of  these  cases  3  were  secondary,. and 
all  favorable. 

The  arm  was  removed  at  the  shoulder-Joint  in  39  cases, 
with  a  fatal  issue  in  13,  or  33-3  per  cent.,  33  being  primary, 
with  9  deaths,  and  6  secondary,  with  a  fatal  issue  in  4.  If  we 
couple  these  cases  with  21  that  occurred  during  the  previous 
period  of  the  war,  we  shall  have  an  aggregate  of  60  cases, 
with  19  deaths,  or  a  mortality  of  31-6  per  cent.  The  advan- 
tage of  a  primary  over  secondary  amputation  of  the  shoulder 
has  long  been  known  to  #iilitary  surgeons.     Thus,  of  19  pri- 


MILITARY   SURGERY.  46 

mary  cases  mentioned  by  Mr.  Guthrie  as  having  occurred  be- 
tween June  and  September,  1813,  18  recovered,  while  of  19 
secondary  cases  15  died.  The  experience  of  the  late  Dr. 
Thomson,  in  Belgium,  is  equally  decisive. 

Amputation  of  the  upper  arm  was  performed  102  times, 
with  death  in  25  cases,  or  mortality  of  24-5;  96  of  the  cases 
being  primary.     Of  the  secondary  cases  one-half  proved  fatal. 

The  forearm  was  amputated  primarily  52  times,  and  the 
hand  at  the  wrist  once,  with  only  one  death  ;  while  of  7  second- 
ary operations,  upon  the  same  parts,  2  died. 

Resection  is  one  of  the  aids  of  conservative  surgery,  and 
military  practice  affords  numerous  occasions  for  its  employ- 
ment. The  operation,  however,  is  not  equally  applicable  to 
all  the  articulations.  Resection  of  the  shoulder 'joint  has 
hitherto  afforded  the  most  flattering  results.  It  is  more  espe- 
cially applicable  in  cases  of  gunshot  injuries,  unattended 
by  serious  lesion  of  the  vessels  and  nerves  of  the  limb,  or 
severe  laceration  of  the  muscles  and  integuments.  A  portion 
of  the  humerus,  embracing,  if  necessary,  from  four  to  five 
inches  in  length,  together  with  a  part  or  even  the  whole  of 
the  glenoid  cavity  of  the  scapula,  may  be  safely  and  expedi- 
tiously removed  under  such  circumstances,  and  yet  the  patient 
have  an  excellent  use  of  his  arm. 

Williams  mentfons  19  cases  of  gunshot  wounds  of  the 
«houlder-joint  in  which  resection  was  performed,  and  of  which 
3  proved  fatal.  Baudens  saved  13  out  of  14  cases,  and  the 
British  surgeons,  in  the  Crimea,  lost  2  patients  out  of  27. 

Resection  of  the  dboio  has  of  late  engaged  much  attention 
among  military  men,  and  although  the  results  are  less  flatter- 
ing than  in  the  operation  upon  the  shoulder,  they  are,  never- 
theless, highly  encouraging.  Of  82  cases  which  occurred  in 
the  Schleswig-Holstein  and  in  the  Crimean  campaigns,  only 
16  died,  or  1  in  about  5. 

The  wrist-joint  has  seldom  been  the  subject  of  excision ; 
doubtless,  cases  not  unfrequently  occur  in  which  it  might  be 
resorted  to  with  advautage. 


46  MILITARY   SURGERY. 

Dr.  George  Williams  has  collected  the  history  of  11  cases 
of  excision  of  the  lii.p-joint  for  gunshot  injury,  6  of  which 
ocQAJrred  in  the  Crimea.  Of  this  number  10  died.  Of  23 
amputations  at  the  hip-joint  by  the  English  and  French  sur- 
geons in  the  East,  all  died. 

Excision  of  the  knee-joint  for  gunshot  injury  holds  out  no 
prospect  of  advantage,  experience  having  shown  that,  when 
the  articulating  extremities  of  the  femur  and  tibia  are  frac- 
tured by  a  ball,  the  proper  remedy  is  amputation. 

The  ankle-joint  has  been  resected  in  a  few  instances  only 
for  gunshot  injuries,  and  the  results  have  thus  far  been  by  no 
means  flattering.  When  the  joint  is  seriously  implicated, 
amputation  will  undoubtedly  be  the  more  judicious  pro- 
cedure. 

Resection  of  the  bones  in  their  continuity  is  seldom  prac- 
ticed in  this  class  of  injuries,  and  experience  has  offered 
nothing  in  its  favor.  The  operation  was  performed  several 
times  in  the  Crimea,  but  proved  invariably  fatal. 

The  after-treatment  in  resection  must  be  conducted  upon 
the  same  principles  as  in  amputation.  The  measures  must, 
for  the  most  part,  be  of  a  corroborating  nature.  The  limb 
must  be  placed  in  an  easy  position,  and  be  well  supported  by 
a  splint  or  fracture-box,  to  prevent  motion.  The  operation  is 
liable  to  be  followed  by  the  same  bad  effects  as  amputations. 


CHAPTER   YII. 
ILL  CONSEQUENCES  OF  WOUNDS  AND  OPERATIONS. 

The  bad  consequences  to  be  apprehended  after  wounds, 
amputations,  and  other  operations,  are  traumatic  fever,  hem- 
orrhage, excessive  suppuration,  spasms,  erysipelas,  gangrene, 
pyemia,  and  tetanus. 

a.   Traumatic  fever  usually  sets  within  the  first  few  hours 


MILTTARY   SURGERY.  47 

after  the  injury,  or  soon  after  reaction  has  JDieen  fairly  estab- 
lished. In  camp  practice  its  tendency  generally  is  to  assume 
a  low,  typhoid  character,  especially  if  there  is  much  crowding 
of  the  sick,  with  imperfect  ventilation  and  want  of  cleanli- 
ness. Not  unfrequently  it  displays  an  endemic  or  epidemic 
disposition. 

The  treatment  must  be  exceedingly  mild;  the  patient  will 
not  bear  depiction,  but  will,  notwithstanding  this  fever,  pro- 
bably require  stimulants  and  tonics,  with  nutritious  food  and 
drink  from  the  very  commencement.  A  gentle  anodyne  and 
diaphoretic  mixture,  as  morphia  and  antimony  in  camphor- 
water,  may  be  needful,  in  the  early  stage,  to  quell  the  ficti- 
tious excitement  or  attempt  at  overaction. 

b.  The  likelihood  of  secondari/  hemorrhage  must  be  steadily 
kept  in  view  in  these  cases;  much  may  be  done  to  prevent  it 
by  the  proper  use  of  the  ligature  at  the  time  of  the  operation 
or  dressing,  but  it  is  often  unavoidable,  especially  in  gunshot 
wounds,  owing  to  the  injury  sustained  by  the  coals  of  the 
vessels  by  the  grazing  of  the  ball.  However  induced,  it 
should  receive  the  most  prompt  attention,  inasmuch  as  the 
loss  even  of  a  few  ounces  of  blood  may  prove  destructive  to 
the  already  exhausted  system. 

c.  Spasm  of  the  muscles  is  not  peculiar  to  amputations ; 
it  often  exists  in  a  most  severe  degree  in  cases  of  fractures 
and  gunshot  wounds.  Anodynes  in  full  doses,  with  a  little 
antimony,  the  use  of  a  moderately-tight  bandage,  and  warm 
water-dressing,  medicated  with  laudanum  and  acetate  of  lead, 
are  the  most  appropriate  measures. 

d.  Profuse  suppuration  may  be  looked  for  in  nearly  all  bad 
wounds,  whatever  their  character,  and  also  in  many  of  the 
amputations  performed  on  the  field  of  battle.  The  exhaust- 
ing effects  must  be  counteracted  by  supporting  remedies,  as 
quinine,  iron,  cod-liver  oil,  and  brandy,  with  frequent  change 
of  dressing,  cleanliness,  and  ventilation.  Bagging  is  prevented 
by  counter-openiugs  and  careful  bandaging. 

e.  Erysipelas  usually  manifests  itself  within  the  first  thirty- 


48  *       MILITARY   SURGERY. 

six  hours  after  the  injury  or  operation  ;  often  assumes  an  en- 
demic or  epidemic  character;  is  easily  distinguished  by  the 
peculiar  reddish  blush  rapidly  spreading  ov^r  the  surface, 
together  with  the  stinging  or  smarting  pain  and  increased 
swelling;  and  should  be  treated  with  dilute  tincture  of 
iodine,  or  anodyne  and  saturnine  lotions,  quinine  and  tincture 
of  iron,  with  nutritious  food  and  drinks. 
,  f.  Gangrene  is  sufficiently  common  after  severe  lesions  on 
the  battle-field,  especially  that  variety  of  it  denominated  hos- 
pital gangrene.  During  the  Crimean  war,  this  form  of  gan- 
grene raged  with  extraordinary  virulence  and  fatality  among 
the  French  in  the  hospitals  on  the  Bosphorus.  It  also  pre- 
vailed about  the  same  period  within'  some  of  the  hospitals  in 
the  south  of  France,  and  it  is  asserted  that- the  "Euphrate,'' 
a  transport  ship,  in  her  voyage  to  the  Mediterranean  was 
obliged,  from  this  cause  alone,  to  throw  sixty  of  her  men 
overboard  within  thirty-six  hours  !  After  the  taking  of  the 
Quarries  and  the  assault  upon  the  Kedan,  during  the  heat  of 
summer,  in  1855,  the  English  surgeons  lost  a  number  of  their 
cases  of  amputation  of  the  thigh  from  moist  gangrene  of  a 
most  rapid  character,  the  system  having  been  literally  over- 
whelmed by  the  poison.  When  hospital  gangrene  is  endemic, 
it  attacks  not  only  open  wounds  and  sores,  but  also  the 
slightest  scratches,  cicatrices,  and  stumps.  Persons  laboring 
under  diarrhoea,  dysentery,  and  scurvy  are  most  obnoxious 
to  it. 

The  proper  remedies  are  sequestration  of  the  patients,  the 
free  use  of  the  nitric  acid  lotion,  iodine  to  the  inflamed  skin, 
charcoal,  port  wine,  or  yeasi;  cataplasms,  and  frequent  ab- 
lutions with  disinfecting  fluids,  aided  by  opium,  quinine, 
tincture  of  iron,  lemon-juice,  and  other  supporting  means. 
Mopping  the  afi'ected  surface  freely  with  strong  nitric  acid 
often  answers  an  excellent  purpose.  The  favorite  remedy  of 
Pouteau  was  the  actual  cautery. 

g.  Fyemia,  the  purulent  infection  of  the  French  writers,  is 
one  of  the  chief  dangers  after  severe  wounds  and  operations. 


MILITARY   SURGERY.  49 

It  was  the  great  source  of  the  mortality  after  amputations, 
especially  secondary,  during  the  war  in  the  Crimea.  It 
usually  comes  on  within  from  three  to  eight  days  after  the 
injury,  and  is  nearly  always  fatal.  Its  characteristic  symp- 
toms are  rigors,  followed  by  copious  sweats,  rapid  failure  of 
the  vital  powers,  delirium,  and  a  withered  appearance  of  the 
countenance,  frequently  conjoined  with  an  ictorode  tinge  of 
the  eye  and  skin.  On  dissection,  the  large  veins  leading 
from  the  stump  or  wound  are  found  filled  with  pus,  with  red- 
ness of  the  lining  membrane;  and  abscesses,  usually  small 
and  filled  with  unhealthy  fluid,  are  seen  scattered  through  the 
lungs,  muscles,  and  cellular  substance,  matter  also  occasion- 
ally existing  in  the  joints.  The  treatment  is  essentially  the 
same  as  in  erysipelas. 

li.  Traumatic  tetanus  is  not  very  common  in  military  prac- 
tice. It  is  most  liable  to  show  itself  in  tropical  countries,  in 
hot,  damp  weather,  and  in  persons  of  a  nervous,  irritable 
temperament,  occasionally  supervening  upon  the  most  insig- 
nificant injuries,  as,  for  example,  a  mere  scratch.  In  India 
the  disease  is  often  provoked  by  unextracted  balls,  and  both 
in  that  country  and  on  the  continent  of  Europe  the  operation 
which  was  most  frequently  followed  by  it  during  the  recent 
wars,  was  amputation  at  the  shoulder-joint. 

The  effects  of  sudden  vicissitudes  of  temperature  in  devel- 
oping tetanus,  are  well  known.  They  are  most  striking  in 
trd^ical  regions,  when  the  change  is  from  hot  to  cold,  or  from 
dry  to  wet.  Larrey  had  repeated  opportunities  of  observing 
the  development  of  the  disease  under  such  circumstances, 
both  in  Egypt  and  Germany.  After  the  battle  of  Bautzen, 
the  exposure  of  the  wounded  to*  the  cold  night  air  produced 
over  a  hundred  cases  of  tetanus,  and  a  large  number  suffered 
from  a  similar  cause  after  the  battle  of  Dresden.  Like  eff"ects 
were  witnessed  at  Ferozepore  and  Chillianwallah.  Baudens, 
in  his  treatise  on  gunshot  wounds,  states  that  the  influence  of 
cold  and  moisture  in  developing  the  disease,  during  the  French 
campaigns  in  Africa,  was  most  striking.  Of  forty  slightly 
3 


60  MILITARY   SURGERY. 

•founded  men,  placed  in  a  gallery  on  the  ground  floor,  during 
the  prevalence  of  a  northeasterly  wind,  fifteen  were  speedily 
attacked  with  tetanus.  Similar  effects  have  several  times  been 
noticed  in  this  country.  Thus,  after  the  battle  of  Ticonderoga, 
in  1758,  nine  of  the  wounded  who  were  exposed  the  whole 
night  after  the  "action,  in  open  boats  upon  Lake  George,  died 
of  lock-jaw;  and  during  our  war  with  Great  Britain,  most  of 
those  who  suffered  on  board  the  Amazon,  in  the  engagement 
before  Charleston,  were  attacked  with  this  disease  a  fortnight 
after,  in  consequence  of  a  very  sudden  change  of  weather,  the 
wind  blowing  cold  and  wet. 

The  extremes  of  heat  and  cold  both  favor  the  production  of 
tetanus.  In  the  East  and  West  Indies,  the  slightest  prick  of 
the  finger  or  toe  is  often  sufficient  to  induce  the  disease,  and 
the  inhabitants  of  the  Arctic  regions  not  unfrequently  suffer 
in  a  similar  manner.  Dr.  Kane,  in  his  memorable  expedition, 
lost  two  of  his  men  from  this  affection,  and  he  adds  that  all  his 
dogs  perished  from  a  like  cause. 

The  mortality  from  traumatic  tetanus  is  notorious.  Hardly 
one  recovers.  Nearly  all  perish  in  two  or  three  days  from  the 
attack. 

The  most  reliable  remedies  are  opium,  in  the  form  of  mor- 
phia or  acetated  tincture,  in  large  doses,  in  union  with  cam- 
phor and  antimony.  The  effects  of  Indian  hemp  are  uncertain. 
Chloroform  will  mitigate  pain  and  spasms.  Amputation, 
except,  perhaps,  when  the  wound  affects  a  finger  or  toe,  will 
be  worse  than  useless,  as  will  also  be  counter-irritation  along 
the  spine.  To  prevent  the  disease  should  be  our  business ; 
and  to  do  this  no  wounded  person  should  ever  be  exposed  to 
the  cold  night  air,  or  to  currents  of  air  at  any  time.  After  all 
amputations,  Jioicever  trtJUn^,  special  directions  should  he 
given  upon  this  point. 


MILITARY   SURGERY.  51 


CHAPTER  YIII. 
INJURIES  OF  THE  HEAD,  CHEST,  AND  ABDOMEN. 

•  The  immediate  effects  of  concussion  of  the  brain  arc  those 
of  fainting  or  collapse,  and  must  be  treated  accordingly;  by 
recumbency,  access  of  cold  air,  the  use  of  the  fan,  dashing  of 
cold  water  upon  the  face  and  chest,  and  sinapisms  to  the  pre- 
cordic^l  region,  thighs,  feet,  and  spine,  aided,  in  the  more 
severe  cases,  by  stimulating  injections.  If  the  patient  can 
swallow,  he  may  take  a  little  wine  or  brandy.  A  smelling- 
bottle  may  be  held  near,  not  to,  the  nose.  Reaction  is  not 
promoted  too  rapidly,  for  fear  of  secondary  consequences. 

The  period  of  danger  from  collapse  being  over,  the  patient 
is  sedulously  watched,  that  overaction  may  not  occur,  the  risk 
now  being  from  inflammation  ;  or,  the  stage  of  excitement 
being  happily  passed,  from  the  remote  effects  of  the  injury. 
If  the  concussion  was  at  all  severe,  all  bodily  and  mental  ex- 
citement must  be  for  a  long  time  avoided. 

Compression  of  the  brain  arises,  surgically  speaking,  from 
two  causes  only  :  effusion  of  blood  and  depressed  bone.  In 
the  former  case,  the  characteristic  symptoms — insensibility 
and  coma,  dilated  abd  fixed  pupil,  ntertorous  breathing,  and 
paralysis — frequently  do  not  come  until  some  time  after  the 
receipt  of  the  injury.  The  first  synjptoms  will  probably  be 
those  of  concussion,  or  exhaustion.  By-and-by  the  patient 
regains  his  strength,  gets  up,  talks,  or  walks,  and  then  sud- 
denly drops  down,  as  if  he  had  been  shot,  in  a  state  of  utter 
unconsciousness.  The  effusion  of  blood,  kept  in  abeyance 
during  the  collapse,  has  had  full  play,  filling  empty  places, 
and  causing  unmistakeable  effects.  Such  an  occurrence  will  be 
most  apt  to  happen  when  there  has  been  extensive  separation 
of  the  dura  mater,  or  rupture  of  the  middle  meningeal  artery. 


52  MILITARY   SURGERY. 

If,  on  the  other  hand,  the  compression  is  due  to  depression  of 
the  skull,  the  symptoms  are  nearly  always  immediate. 

When  the  case  is  one  of  sanguineous  compression,  it  must 
be  treated  very  much  as  one  of  ordinary  apoplexy ;  at  first, 
bj  efforts  at  gradual  reaction,  and  afterward  by  purgatives, 
bleeding,  and  means  to  favor  cerebral  accommodation  and 
prevent  inflammation.  The  trephine  is  not  thought  of  unless 
the  unconsciousness  obstinately  persists,  and  there  is  reason  fo 
believe,  from  the  nature  of  the  phenomena,  especially  the 
existence  of  a  wound  or  contusion  on  the  head,  that  the  blood 
may  be  reached  by  the  instrument. 

GiinsJiot  injuries  of  the  skull,  with  or  without  lodgn^nt  of 
the  ball,  may  be  productive  merely  of  concussion  of  the  brain, 
or  of  concussion  and  compression.  When  the  missile  pene- 
trates the  bone,  and  tears  up  the  cerebral  tissues  and  mem- 
branes, death  usually  occurs  instantly,  or  within  a  short  time 
after  the  receipt  of  the  accident,  without,  perhaps,  any  attempt 
at  reaction.  Nevertheless,  a  number  of  cases  of  injury  of  this 
nature,  in  which  the  patient  cither  partially  or  completely  re- 
covered, have  been  recorded  by  military  surgeons.  In  some 
instances  the  ball  merely  penetrates  the  skull,  with  no  appa- 
rent depression,  and  in  this  e^ent  the  treatment  should 
evidently  be  very  simple,  being  limited,  in  a  great  degree, 
after  the  occurrence  of  reaction,  to  the  prevention  of  inflamma- 
tion of  the  brain.  A  similar  course  should  be  adopted  when 
the  bone  is  broken  and  only  slightly  depressed,  especially  if 
there  be  no  urgent  or  obstinate  symptoms  of  compression. 
When,  on  the  contrary,  the  bone  is  badly  fractured,  com- 
minuted, or  forced  greatly  beyond  the  natural  level,  the  proper 
plan  is  to  trephine  whether  there  be  any  external  wound  or 
evidences  of  compression  or  not.  If  the  operation  be  neg- 
lected, loss  of  life  from  inflammation  will  be  sure  to  arise 
within  the  first  six  or  ten  days  after  the  receipt  of  the  injury. 
In  the  punctured  fracture,  as  it  is  named,  the  trephine  is 
invariably  employed  at  the  earliest  moment,  however  flattering, 
apparently,  the  head  symptoms  may  be.     If  the  instrument  be 


MILITARY   SURGERY.  53 

TvithhelJ,  fatal  cerebritis  or  arachinitis  will  be  no  less  certaia 
than  when  the  bone  is  shattered  and  driven  down  upon  the 
brain. 

Fracture  of  the  skull  by  contre-coup^  so  common  in  civil 
practice,  is  seldom  met  with  on  the  field  of  battle;  doubtless 
for  the  reason  that  the  injury  is  hardly  ever  inflicted  upon  the 
top  or  the  base  of  the  cranium,  as  it  is  when  a  person  is  struck 
upon  the  vertex  or  falls  upon  his  nates.  The  most  frequent  frac- 
ture among  soldiers  is  the  punctured.  A  ball  has  been  known 
to  break  the  internal  table  of  the  skull  without  the  external. 

The  skull  is  sometimes  frightfully  injured  without  any 
serious  lesion  of  the  scalp.  Macleod  refers  to  a  case,  which 
occurred  at  the  Alma,  where  it  was  completely  destroyed  by  a 
glancing  shot,  without  any  material  implication  of  the  soft 
parts.  A  round  shot  (''en  ricochet")  struck  the  scale  from 
an  oflBcer's  shoulder,  and  merely  grazed  his  head  as  it  ascend- 
ed. The  result  was  instant  death.  The  skull  was  so  com- 
pletely mashed  that  its  fragments  rattled  under  its  scalp  as  if 
loose  in  a  bag.  The  condition  of  the  brain  was,  unfortunately, 
not  ascertained. 

In  the  more  simple  forms  of  fractures  of  the  skull,  however 
induced,  the  practice  of  trephining  is  now  much  less  common  ^ 
than  formerly,  and  there  is  no  doubt  that  the  patient  often 
makes  a  good  recovery,  though  it  is  by  no  means  certain  that 
such  a  person  may  not  suffer  seriously,  at  a  more  or  less  remote 
period,  from  epileptic  and  other  affections.  I  am  convinced 
from  my  own  observation  that  this  happens  not  unfrequently. 
Dr.  Stroraeyer,  surgcon-in-chief  in  the  Schleswig-Holstein 
campaign  in  ISJTO,  expresses  strong  opposition  to  the  use  of 
the  trephine  in  gunshot  and  other  fractures  of  the  skull,  even 
with  depression,  on  the  ground  that,  independently  of  tho 
mischief  inflicted  in  the  operation  upon  the  tissues,  admission 
of  air  to  the  contused  portion  of  the  brain  greatly  augments 
the  danger  of  inflammation.  Of  41* cases  of  gunshot  fractures 
of  the  skull  with  depression,  reported  by  him,  34  were  cured, 
and  of  these  1  only  had  been  trephined. 


54  MILITARY   SURGERY. 

When  operative  interference  is  deemed  improper,  the  most 
simple  treatment  should  be  enforced.  Any  probing  that  may 
be  necessary  should,  if  practicable,  be  performed  with  the 
finger,  and  the  wound  should  not  be  enlarged,  except  when  we 
are  compelled  to  elevate  depressed  or  remove  loose  bone. 

When  trephining  is  required,  it  should  be  done  as  early  as 
possible,  and  without  chloroform  or  ether,  unless  the  patient 
is  very  unruly,  as  the  anaesthetic  might  tend  to  provoke  in- 
flammation of  the  brain.  Every  particle  of  depressed  bone 
should  be  elevated,  and  such  portions  as  are  loose,  detached, 
or  driven  into  the  brain,  and  easily  accessible,  removed.  All 
bleeding,  vessels  are  tied,  the  edges  of  the  wound  are  gently 
approximated  with  silver  sutures,  and  the  head,  well  shaved 
and  raised,  wrapped  in  warm  or  cold  water-dressing,  as  may 
be  most  grateful  to  part  and  system.  The  great  danger  after 
all  severe  injuries  and  operations  upon  the  skull  is  inflamma- 
tion of  the  brain  and  of  its  membranes,  and  to  the  prevention 
of  this,  therefore,  the  surgeon  should  direct  his  most  zealous 
efi'orts.  The  patient  must  be  frequently  visited,  and  every 
untoward  symptom  promptly  met  by  appropriate  measures,  of 
which  active  purgation,  loss  of  blood  by  venesection,  leeching 
^  or  cupping,  a  restricted  diet,  and  exclusion  of  light  and  noise 
from  the  apartment,  with  perfect  rest,  are  the  most  reliable. 

Wounds  of  the  brain  must  be  managed  upon  general  prin- 
ciples; all  foreign  matter  is  at  once  removed,  and  the  parts 
being  restored  as  nearly  as  may  be  to  their  normal  relations, 
the  surgeon  endeavors  to  keep  the  resulting  inflammation 
within  proper  limits.  Most  of  such  lesions  prove  fatal  within 
the  first  "week  from  their  receipt.  If  the  patient  survive  for 
any  length  of  time,  death  will  generally  come  at  last  from 
exhaustion,  cerebritis,  or  fungus. 

Portions  of  the  slcull^  sliced  off"  by  the  sabre  or  sword, 
should  be  replaced  and  secured  by  wire  sutures,  ,even  if  they 
are  attached  merely  by  small  shreds  of  the  scalp. 

Scalp  wounds  of  every  description,  but  in  particular  the 
contused,  lacerated,  punctured,  and  gunshot,  are  extremely 


MILITARY   SURGERY.  55 

prone  to  be  followed  by  erysipelas;  death  may  also  occur  from 
cerebritis,  arachnitis,  and  pyemia.  The  slightest  lesion,  then, 
of  this  region  of  the  body  should  be  zealously  watched. 

Wounds  of  the  face  must  be  treated  with  an  eye  to  the  avoid- 
ance of  disfiguring  scars,  by  wire  sutures  and  cold  water-dress- 
ing. When  a  large  portion  of  the  lower  jaw  is  shot  away,  the 
tongue  will  be  apt  to  fall  back  upon  the  glottis,  causing  suffo- 
cation. The  organ  should  be  drawn  forward  with  the  finger 
or  tenaculum,  and  the  patient  observe  the  prone  position  until 
the  tendency  is  lost. 

One  of  the  great  sources  of  annoyance  and  danger,  in 
gunshot  wounds  of  the  face,  is  secondary  hemorrhage."  It 
frequently  appears  soon  after  the  accident,  and,  although  it 
often  ceases  spontaneously,  it  is  sometimes  controlled  with 
much  difficulty.  Paralysis,  partial  or  complete,  is  not  uncom- 
mon, owing  to  injury  of  the  branches  of  the  facial  nerve. 

In  the  management  of  wounds  about  the  mouth,  throat,  and 
face,  great  care  must  be  taken  not  to  allow  the  offensive  mu- 
cous and  salivery  secretions  to  pass  into  the  stomach.  The 
neglect  of  this  precaution  is  apt  to  be  followed  by  a  low  typhoid 
state  of  the  system,  very  similar  to  what  occurs  in  pyemia,  or 
blood  poisoning.  I  have  repeatedly  witnessed  these  effects 
after  operations  upon  the  jaws,  mouth,  and  even  the  nose. 

In  fractures  of  the  bones  of  the  face  from  gunshot  an  ex- 
ception should  be  made  to  the  general  rule  of  removing  frag- 
ments which  are  nearly  detached,  observation  having  shown, 
says  Mr.  Macleod,  that  the  large  supply  of  blood  in  this  region 
will  enable  them  to  resume  their  connection  with  the  other 
tissues,  in  a  way  that  would  be  fatal  to  similarly  placed  por- 
tions in  other  situations. 

Gunshot  and  other  wounds  of  the  c/ics^  are,  as  stated  else- 
where, extremely  fatal;  death,  if  the  lesion  be  at  all  severe, 
being  usually  speedily  caused  by  shock,  hemorrhage,  or  as- 
phyxia; or,  at  a  more  or  less  remote  period,  by  inflammation 
and  effusion.  When  the  lungs  are  wounded,  the  characteristic 
symptoms  will  be  hemoptysis,  with  suffocative  cough,  great 


56  MILITARY   SURGERY. 

prostration,  and  excessive  alarm.  A  copious  flow  of  blood 
may  take  place  in  the  thoracic  cavity  from  a  wound  of  one  of 
the  intercostal  arteries. 

Any  foreign  matter  that  is  easily  accessible,  is  at  once  re- 
moved, but  officious  probing  is  out  of  the  question.  The 
wound,  if  small  and  unaccompanied  by  serious  hemorrhage, 
is  closed  in  the  usual  manner,  the  chest  being  firmly  encir- 
cled by  a  broad  bandage,  to  compel  diaphragmatic  respiration. 
Under  opposite  circumstances,  it  is  kept  open,  the  patient  ly- 
ing upon  the  aff'ected  side  to  favor  the  escape  of  blood  with  as 
much  elevation  of  the  head  as  the  case  may  admit  of.  The 
main  reliance  for  arresting  pulmonary  bleeding  is  upon  vene- 
section, copious,  and  frequently  repeated,  unless  the  exhaus- 
tion amounts  to  absolute  collapse.  Sugar  of  lead,  opium,  and 
veratrum  viride  are  frequently  exhibited,  sinapisms  are  ap- 
plied to  the  extremities,  and,  in  short,  everything  is  done  to 
control  cardiac  action.  Inflammatory  symptoms  are  counter- 
acted in  the  usual  manner,  and  efl"used  fluids,  causing  oppres- 
sion, and  resisting  ordinary  measures,  are,  unhesitatingly, 
evacuated  by  puncture,  as  the  only  chance  of  escape. 

Wounds  of  the  heart  and  aorta,  of  whatever  nature,  are 
usually  fatal ;  now  and  then,  however,  an  astonishing  excep- 
tion occurs. 

Wounds  of  the  abdomen,  merely  penetrating  its  walls,  but 
not  its  contents,  are  brought  together  by  sutures,  extending 
down  nearly  to  the  peritoneum,  otherwise  they  will  be  fol- 
lowed by  hernia.  When  they  involve  the  intestine,  and  are 
incised,  they  are  sewed  up  with  a  fine  needle  and  silk  thread, 
either  interruptedly  or  continuously,  the  ends  of  the  ligature 
being  cut  off  close. 

Contusions  of  the  walls  of  the  abdomen  by  round  shot  are 
among  the  most  dangerous  injuries  to  which  the  body  is  ex- 
posed, often  rupturing  both  the  hollow  and  solid  viscera,  and 
rapidly  causing  death,  without  much  apparent  sign  of  so  se- 
vere an  accident.  The  most  important  symptoms  of  these 
contusions  are  vomiting  and  pain  in  the  abdomen ;  and  the 


MILITARY   SURGERY.  67 

great  object  of  the  treatment,  ia  the  event  the  patient  sur. 
vives  tBeir  immediate  efiFects,  is  the  prevention  of  peritonitis, 
which  often  comes  on  in  the  most  stealthy  manner.  Lacera- 
tion of  an  internal  organ  is  nearly  always  promptly  fatal. 
Shell  wounds  of  the  walls  of  the  abdomen  are  generally  fol- 
lowed by  extensive  sloughing.  Abscesses  among  the  muscles 
of  the  abdomen  are  not  uncommon  after  gunshot  injuries. 

Balls  often  traverse  the  walls  of  the  abdomen  for  a  consid- 
erable distance  without  entering  its  cavity,  or  they  pass  in 
without  injuring  any  of  the  contained  viscera. 

"  The  fatality  of  penetrating  wounds  of  the  belly,"  ob- 
serves Macleod,  "  will  depend  much  on  the  point  of  their 
infliction.  Balls  entering  the  liver,  kidneys,  or  spleen,  are 
well  known  to  be  usually  mortal,  although  exceptional  cases 
are  not  rare.  Wounds  of  the  groat  gut  are  also  always  recog- 
nized as  much  less  formidable  than  those  which  implicate  the 
small.  Thomson  saw  only  two  cases  of  wounds  of  the  small 
gut,  after  Waterloo,  in  the  way  of  recovery ;  but  Larrey  re- 
ports several.  Gunshot  wounds  of  the  stomach  are  also 
exceedingly  fatal.  Baudens  records  a  remarkable  case  of  re- 
covery, although  complicated  with  severe  head  injuries.  The 
syncope  which  followed  the  severe  hemorrhage  in  this  case 
lasted  for  ten  hours,  and  doubtless  assisted,  along  with  the 
empty  state  of  the  stomach  at  the  moment  of  injury,  in  pre- 
venting a  fatal  issue." 

Gunshot  wounds  of  the  hladdcr  occasionally  occur;  the 
ball  may  penetrate  the  organ  in  any  direction,  and  at  the  same 
time  commit  extensive  havoc  in  the  neighboring  parts,  both 
soft  and  osseous.  Such  lesions  are  generally  fatal.  Simple 
gunshot  wounds,  on  the  contrary,  are  sometimes  recovered 
from,  especially  when  they  are  treated  by  the  retention  of  the 
catheter,  thus  allowing  the  urine  to  flow  off  as  fast  as  it  de- 
scends from  the  kidneys.  The  operation  of  laying  open  the 
wounded  viscus  throjigh  the  perineum,  as  originally  proposed 
by  Dr.  Walker,  of  Massachusetts,  might  be  performed  in  such 
a  contingency.     Such  a  procedure  would  be  much  more  likely 


58  MILITARY  SURGERY. 

to  prevent  urinary  infiltration  than  the  catheter,  however  care- 
fully retained,  during  the  detachment  of  the  sloughs,  as  well 
as  before  the  contiguous  structures  have  been  glazed  with 
lymph. 

Balls,  pieces  of  cloth,  fragments  of  bone,  and  other  foreign 
bodies,  if  retained  in  the  bladder,  generally  serve  as  nuclei 
calculi,  and  should,  therefore,  be  as  speedily  extracted  as  pos- 
sible, either  through  the  perineum,  or  by  means  of  the  forceps 
or  lithotriptor.  Quite  a  number  of  cases,  in  which  the  opera- 
tion of  lithotomy  was  successfully  performed  for  the  purpose 
of  effecting  the  riddance  of  balls  and  other  extraneous  sub- 
stances, have  been  reported  by  different  writers,  as  Morand, 
Larrey,  Baudens,  Langenbeck,  Guthrie  and  Hutin. 


CHAPTER   IX. 

DISEASES  INCIDENT  TO  TROOPS. 

The  diseases  which  attend  armies,  or  molest  soldiers  in 
camps,  garrisons  and  hospitals,  and  which  so  often  decimate 
their  ranks,  and  even,  at  times,  almost  annihilate  whole  regi- 
ments, are  the  different  kinds  of  fevers,  especially  typhus  and 
typhoid,  dysentery,  diarrhoea,  and  scurvy.  Tbese  are,  em- 
phatically, the  enemies  of  military  life,  doing  infinitely  more 
execution  than  all  the  weapons  of  war,  however  adroitly  or 
eflficiently  wielded,  put  together.  Pneumonia,  pleurisy,  and 
hepatitis,  of  course,  slay  their  thousands,  and  various  epi- 
demics, especially  cholera,  not  unfrequently  commit  the  most 
frightful  ravages.  "  War,"  says  Johnson,  "  has  means  of 
destruction  more  formidable  than  the  cannon  and  the  sword. 
Of  the  thousands  and  tens  of  thousands  that  have  perished, 
how  small  a  proportion  ever  felt  the  stroke  of  an  enemy  !" 
Frederick  the  Great  used  to  say  that  fever  cost  him  more  men 
than  seven  pitched  battles,  and  it  has  long  been  a  matter  of 


MILITARY  SURGERY.  59 

history  that  more  campaigns  are  decided  by  sickness  than  by 
the  sword.  The  groat  mortality  which  attended  our  armies 
in  Mexico  was  occasioned,  not  by  wounds  received  in  battle, 
but  by  the  diseases  incident  to  men  carrying  on  their  military 
operations  in  an  inhospitable  climate,  badly  fed,  subjected  to 
fatiguing  marches,  and  obliged  to  use  unwholesome  water. 
Thousands  perished,  during  their  absence,  from  fever,  dysen- 
tery and  diarrhoea,  and  a  still  greater  number  from  the  effects 
of  these  diseases,  after  the  return  of  the  troops  to  their  native 
soil.  The  latter  affection,  in  particular,  pursued  many,  like  a 
relentless  foe,  to  their  graves  long  after  they  had  been  cheered 
by  the  sight  of  their  homes  and  friends. 

In  the  war  in  the  Crimea  disease  destroyed  incomparably 
more  soldiers  than  the  sword,  the  musket,  and  the  cannon. 
Typhus  and  typhoid  fever,  dysentery,  diarrhoea,  scurvy,  and, 
lastly,  malignant  cholera,  annihilated  vast  numbers,  both  in 
the  British,  French  and  Russian  ranks.  According  to  Dr. 
Macleod,  whose  "Notes  on  the  Surgery  of  the  War  in  the 
Crimea,"  are  so  well  known  to  the  profession,  the  proportion 
of  those  lost  among  the  British  by  sickness  to  those  lost  by. 
gunshot  and  other  injuries,  was,  during  the  entire  campaign, 
as  16,211  to  17G1,  exclusive  of  those  killed  in  action.  The 
difference  he  supposed  to  have  been  still  greater  among  the 
French  and  Russian  forces.  In  December,  1854,  and  in  Jan- 
uary, 1855,  not  less  than  14,000  French  soldiers  were 
admitted  into  the  Crimean  ambulances  on  account  of  disease, 
whereas,  during  the  same  period,  only  1500  were  admitted  on 
account  of  wounds.  Of  the  whole  number  nearly  2000  died- 
Bering  the  last  six  months  of  the  campaign,  in  which  the  city 
was  stormed  and  taken,  the  French  had  21,957  wounded  as  an 
offsot  against  101,128  cases  of  disease.*  At  Walcheren,  in 
1809,  the  British  lost  one-third  of  their  troops  by  disease, 
and  only  16  per  cent,  by  wounds.  In  the  Peninsular  war, 
from  January,  1811,  to  May,  1814,  out  of  an  effective  force 

*  Macleod,  op.  cit.,  p.  67. 


60  MILITARY   SURGERY. 

of  61,500  men,  only  42.4  per  1000,  says  Macleod,  were  lost 
by  wound?,  while  118  6  were  lost  by  disease. 

The  number  of  sick  that  may  be  expected  to  be  constantly 
on  hand  during  any  given  campaign  is  estimated,  on  an  aver- 
age, at  10  per  cent.;  but  this  proportion  must  necessarily  be 
exceeded,  especially  in  an  invading  army,  with  raw,  undisci- 
plined and  unacclimated  troops.  This  was  eminently  true 
even  in  the  Crimea,  in  a  dim. ate  comparatively  healthy,  witliin 
a  few  miles  of  the  sea.  We  may  wall  imagine  what  would 
be  the  effects  of  the  climate  of  the  South  upon  the  Northern 
troops,  if  they  were  to  pass  far,  during  the  hot  season,  be- 
yond Mason  and  Dixon's  line.  Disease,  in  its  worst  form, 
would  be  sure  to  invade  and  thin  their  ranks  at  every  step. 
Fever — typhoid,  typhus,  remittent,  intermittent,  and  yellow — 
dysentery,  diarrhoea,  scurvy,  pneumonia,  and  inflammation 
of  the  liver,  would  accomplish  more,  infinitely  more,  for  the 
Southern  cause  than  all  the  weapons  of  war  that  could  be 
placed  in  the  hands  of  the  Southern  people.  Typhoid,  typhus 
and  yellow  fever,  dysentery,  diarrhoea  and  scurvy  would,  in 
all  human  probability,  soon  become  epidemic,  and  occasion  a 
mortality  truly  appalling.  The  Southern  soldier,  on  the  con- 
trary, thoroughly  acclimated  as  he  is,  would  suffer  compara- 
tively little.  The  British  in  the  Crimean  war  lost  5,910  men 
from  diarrhoea  and  dysentery,  the  whole  number  of  cases 
having  been  52,442,  affording  thus  a  mortality  of  11.26  per 
cent.  Cholera,  of  which  there  were  7,575  cases  altogether, 
destroyed  4,513,  or  in  the  ratio  of  59-57  per  cent.  Typhus 
fever  killed  285  out  of  828  cases ;  fever  not  typhus,  8,161, 
out  of  30,376.  The  French  and  Russian  troops  suffered  in 
still  larger  numbers  from  these  diseases.  Macleod  asserts  that 
the  former  lost  their  men  by  typhus  fever  by  thousands,  and 
the  latter  by  tens  of  thousands.  The  British  suffered  but 
little  from  intermittent  fever,  whereas  this  disease  did  great 
mischief  among  the  French,  causing  serious  mortality,  either 
directly  or  indirectly,  besides  disqualifying  large  numbers  for 
service. 


MILITARY   SURGERY.  61 

Scurvy  was  another  dreadful  enemy  which  the  British  and 
French  troops  were  compelled  to  encounter  in  the  Crimea. 
It  prevailed  more  or  less  extensively  for  a  long  time,  and 
served  to  impart  its  livery  to  the  other  diseases  of  the  sol- 
diery, masking  their  character,  and  remarkably  augmenting 
their  virulency. 

Considering,  then,  the  frequency  of  the  occurrence  of  these 
diseases,  and  their  excessive  fatality,  it  behooves  the  military 
surgeon  to  use  every  means  in  his  power  to  guard,  in  the  first 
place,  against  their  outbreak,  by  the  employment  of  proper 
hygienic  or  sanitary  measures;  and  in  the  next,  to  treat  them 
with  all  possible  diligence  and  judgment  when  their  develop- 
ment is  unavoidable.  It  is,  of  course,  impossible,  in  a  work 
of  this  description,  to  enter  into  any  details  upon  the  subject; 
but  there  arc  several  points  which  cannot,  I  conceive,  be  too 
forcibly  impressed  upon  the  mind  of  the  military  practitioner. 
I  refer  to  the  great,  the  paramount  importance  of — 1st,  proper 
isolation  of  the  sick,  or,  what  is  the  same  thing,  the  impor- 
tance of  not  crowding  them  together;  2dly,  free  ventilation; 
3dly,  bodily  cleanliness  ;  4thly,  little  medicine;  5thly,  a  good 
supply  of  fresh  vegetables  and  fruits,  especially  oranges  and 
lemons;  6thly,  careful  and  tender  nursing. 

Painful  experience  has  shown  in  all  parts  of  the  world,  that 
the  crowding  together  of  the  sick  and  wounded  is  one  of  the 
worst  calamities  that  can  befall  them.  For  want  of  this  pre- 
caution, diseases,  otherwise  easily  manageable,  often  assume 
an  epidemic  character,  or,  in  the  absence  of  this  character, 
often  baffle  the  best  directed  eflforts  for  their  relief.  When 
the  wounded  are  crowded  together  they  frequently  become 
the  victims  of  erysipelas,  hospital  gangrene,  pyemia^^  and 
phlebitis;  occurrences  which,  under  better  regulations,  might 
in  many  cases  be  entirely  prevented. 

Of  the  propriety  of  constant  and  thorough  ventilation,  it  is 
unnecessary  to  speak.  If  pure  air  is  so  essential  in  health, 
it  is  easy  enough  to  see  how  important  it  must  be  in  sickness. 

Cleanliness  of  body  should  be  regarded  as  a  religious  duty ; 


62  MILITARY  SURGERY. 

it  may  be  effected  with  the  sponge  and  tepid,  cool  or  cold 
water,  according  to  the  exigencies  of  the  case,  and  cannot  be 
performed  too  frequently  or  too  thoroughly,  care  being,  of 
course,  taken  not  to  worry  or  fatigue  the  patient.  In  some 
instances  the  water  may  be  medicated  with  common  salt,  po- 
tassa,  vinegar,  or  Labarraque's  solution.  Nothing  is  generally 
more  grateful  to  the  sufferer,  in  the  different  kinds  of  fevers, 
than  frequent  sponging  of  the  surface  with  cool  or  tepid 
water. 

The  use  of  heroic  medicines,  or  of  any  medicines  in  large 
doses,  in  these  diseases,  and  also  in  cases  of  severe  wounds, 
cannot  be  too  severely  reprobated.  More  men,  there  is 
reason  to  believe,  have  been  killed  in  this  manner  in  the 
armies  and  navies  of  the  world  than  by  the  sword  and  the 
cannon.  Let  medicines,  then,  be  administered  sparingly. 
Let  the  secretions  be  well  seen  to ;  but  purge  little,  and  use 
depressants  with  all  possible  wariness.  Give  iced  water,  but 
not  too  freely,  and  lumps  of  ice  when  there  is.  much  thirst 
with  gastric  irritability  and  excessive  restlessness.  Mild  dia- 
phoretics and  anodynes,  will,  as  a  general  rule,  be  highly  effi- 
cacious, but  the  latter  should  be  exhibited  with  great  caution 
when  there  is  cerebral  oppression.  Lemon-juice  and  potassa 
are  indispensable  in  scurvy,  or  where  there  is  a  marked  ten- 
dency to  scorbutic  disease.  Quinine  is  one  of  the  great 
remedies  in  most,  if  .not  in  all,  of  these  diseases,  especially 
when,  as  is  so  often  the  case,  they  are  associated  with  a  mala- 
rious origin.  The  good  average  dose  is  from  two  to  five 
grains,  repeated  from  three  to  five  times  in  the  twenty-four 
hours.  When  marked  debility  prevails,  the  best  stimulants 
are  brandy,  in  the  form  of  milk-punch  or  toddy,  and  Madeira, 
Port,  or  Sherry  wine. 

Immense  suffering  and  loss  of  life  are  often  occasioned  for 
the  want  of  fresh  vegetables  and  fruits  in  military  operations, 
as  well  as  in  the  garrison  and  the  hospital.  A  daily  supply 
of  these  articles  should,  therefore,  be  provided  at  almost  any 
hazard  and  expense.     In  all  low  states  of  the  system,  how- 


MILITARY   SURGERY.  63 

ever  induced,  the  strength  can  never  be  rapidly  brought 
up  without  a  diet  which  partakes  more  or  less  of  this  char- 
acter. 

There  is  a  form  of  cli/sentery,  very  common  in  India,  which 
is  exceedingly  apt,  when  large  masses  of  troops  are  habitually 
congregated  together,  to  assume  an  epidemic  character ;  and 
it  is  for  this  reason  that  it  has  often  been  supposed  to  be  con- 
tagious. For  such  an  opinion,  however,  there  does  not  seem 
to  be  any  valid  reason.  Ballingall,  who  witnessed  at  least 
2,000  cases  of  this  disease,  asserts  that  he  never  once  met 
with  a  circumstance  tending  to  create  such  a  suspicion;  and 
the  views  advanced  by  this  eminent  surgeon  are  those  now 
pretty  generally,  if  not  universally,  entertained  by  the  British 
practitioners  in  India. 

"The  remote  causes  of  dysentery  in  India  are  conceived  to 
be  heat,  particularly  when  combined  with  moisture;  the  im- 
mediate and  indiscriminate  use  of  fruits;  the  abuse  of  spirit- 
uous liquors,  and  exposure  to  currents  of  wind  and  to  noxious 
night-dews.''  Troops  recently  arrived  from  Europe  are  par- 
ticularly prone  to  the  disease. 

Tropical  dysentery  presents  itself  in  two  varieties  of  form, 
the  acute  and  the  chronic.  The  first,  which  is  an  extremely 
fatal  disease,  is  seated  in  the  rectum  and  colon,  the  latter  be- 
ing often  involved  through  nearly  its  entire  extent,  and  it 
frequently  commits  very  serious,  if  not  irreparable,  mischief 
in  these  structures  before  the  patient  and  the  attendant  are 
aware  of  its  true  character,  owing  to  the  absence  of  urgent 
pain  and  pyrexia.  In  general  the  attack  is  ushered  in  by  the 
ordinary  symptoms  of  diarrhoea,  such  as  griping  pain  in  the 
bowels,  and  frequent  calls  to  stool  with  excessive  straining, 
the  evacuations  being,  at  first,  thin  and  copious,  but  without 
fetor  and  but  little  streaked  with  blood.  The  tongue-skin  and 
pulse  are  nearly,  perhaps  entirely,  normal.  Gradually  the 
pain  becomes  more  violent,  as  well  as  more  fixed,  and  is  felt 
in  both  iliac  regions,  or  even  along  th^e  whole  track  of  the 
colon ;  the  discharges  consist  chiefly  of  blood  and  mucus,  or 


C4  MILITARY   SURGERY. 

of  a  fluid  resembling  water  in  which  fresh  beef  has  been 
macerated;  the  tongue  is  covered  with  a  white  coat;  the  skin 
is  either  hot  and  dry,  or  bathed  with  clammy  perspiration; 
and  the  straining  is  so  excessive  as  to  occasion  prolapsus  of 
the  rectum.  The  pulse  is,  even  at  this  stage,  often  but  little 
affected,  being,  perhaps,  only  somewhat  increased  in  quickness. 
Sometimes,  however,  it  is  very  full,  bounding,  and  vibratory, 
without  much  velocity,  and  when  this  is  the  case  it  always, 
according  to  Ballingall,  forebodes  evil.  Toward  the  close  of 
the  attack,  the  passages  are  frequently  involuntary  and  intol- 
erably fetid,  gangrenous  portions  of  the  mucus  coat  of  the 
bowels  are  sometimes  extruded,  and  the  surface  of  the  .body 
emits  a  peculiar,  cadaverous  smell.  The  average  period  at 
which  death  occurs  is  about  one  week,  but  many  cases  linger 
on  much  longer. 

The  remedies  upon  which  the  India  practitioners  mainly 
rely  in  the  treatment  of  this  horrible  form  of  disentery  are 
venesection,  mercury  and  opium ;  leeches,  purgatives,  diapho- 
retics, warm  bathing,  blisters  aod  enemata  being  employed  as 
auxiliaries.  ^  Venesection  is  always  practiced  early,  and,  even 
when  the  patient  is  not  very  robust,  boldly,  it  being,  appa- 
rently, regarded  as  the  sheet-anchor  of  the  physician's  hope. 
Calomel  is  administered  in  doses  of  from  ten  to  twenty  grains, 
along  with  two  or  three  grains  of  opium,  twice  or  thrice  in 
the  twenty-four  hours  ;  and,  while  profuse  salivation  is  dis- 
countenanced, production  of  slight  ptyalisra  is  generally 
9,imed  at. 

Such  treatment  as  this  seems  altog^ether  frightful  to  the 
modern  American  practitioner;  it  strikes  him  as  unnecessa- 
rily harsh,  and  as  well  calculated  to  augment  the  mortality  of 
the  disease.  We  might,  in  this  country,  perhaps  bleed,  and, 
that  pretty  freely,  at  the  very  commencement  of  an  attack  of 
dysentery;  at  all  events,  leech  very  copiously,  but  we  would 
certainly  draw  blood  sparingly  if  the  attack  had  already  made 
serious  constitutional  inroads,  or  if  it  was  of  an  epidemic 
character;  and,  as  to  giving  mercury  with  a  view  to  ptyalism, 


MILITARY   SURaERY.  65 

however  slight,  few  men  would,  I  presume,  be  so  fool-hardy. 
The  India  practitioners  do  not,  it  appears,  employ  quinine  in 
the  treatment  of  this  form  of  dysentery;  a  remedy  so  ex- 
tremely needful  in  many  cases  of  this  disease  as  it  prevails  in 
this  country,  especially  in  our  Southern  latitudes,  where  it  is 
not  uofrequeutly  of  a  malarious  origin. 

The  chronic  form  of  India  dysentery,  termed  hepatic  flux, 
more  frequently  attacks  persons  who  have  been  for  some  time 
inured  to  the  climate  of  that  country,  and  is  always  associated 
with  biliary  derangement.  *'Tliis  flux,  like  the  other,  often 
assumes  at  its  commencement  the  appearance  of  a  common 
diarrhoea,  and  becomes  afterwards  characterized  by  frequent 
and  severe  fits  of  griping,  resembling  colic  pains,  particularly 
urgent  about  the  umbilical  region.  Each  attack  of  griping  is 
generally  succeeded  by  a  call  to  stool,  and  the  evacuations  are 
always  unnatural  in  color  and  consistence,  free  from  any  ad- 
mixture of  blood,  but  generally  of  a  yensty  or  frothy  appear- 
ance, and  accompanied  with  large  discharges  of  flatus;  while 
in  passing  they  are  attended  with  a  sense  of  scalding  about 
the  anus.  The  patient,  after  each  evacuation,  feels  consider- 
ably relieved,  and  hopes  to  enjoy  an  interval  of  ease  ;  but  the 
recurrence  of  the  griping,  accompanied  with  a  sensation  of  air 
passing  through  the  bowels,  and  succeeded  again  by  a  call  to 
stool,  gives  him  little  respite.  From  the  commencement  of 
the  attack,  the  patient  complains  of  nausea,  want  of  relish  for 
his  food,  and  preternatural  thirst,  attended  often  with  a  disa- 
greeable taste  in  the  mouth.  The  tongue  is  furred  or  loaded, 
and  not  unfrequcntly  covered  with  a  yellow  bilious  coat.  The 
pulse  is  quickened  and  the  skin  parched.* 

Cholera  morbus  must,  necessarily,  in  this  country,  espe- 
cially in  our  Southern  latitudes,  and  during  the  hot  summer 
months,  be  a  more  or  less  frequent  attendant  upon  camp 
life,  although  much  may  be  done,  by  a  proper  observance  of 
hygienic  laws,  to  prevent  it.     When  the  disease  breaks  out  it 

*BalUngall'8  Military  Surgery,  p.  511,  1844. 


bb  MILITARY    SURGERY. 

cannot  be  arrested  too  speedily.  The  most  appropriate  reme- 
dies, particularly -in  its  earlier  stages,  are  perfect  quietude, 
abstinence  from  drink,  sinapisms  to  the  epigastrium,  and  an 
efl&cient  dose  of  morphia  and  camphor,  or  even  morphia  alone. 
If  torpor  of  the  liver  exists,  blue  mass  or  a  few  grains  of 
calomel  may  be  advantageously  combined  with  the  anodyne. 
The  swallowing  of  small  lumps  of  ice  wijl  greatly  assist  in 
allaying  the  gastric  irritability.  A  mustard  and  salt  emetic 
will  be  indicated  if  the  stomach  is  loaded  with  ingesta.  The 
bowels  are  quieted  with  an  anodyne  enema;  and  to  relieve 
thirst,  and  reduce  heat  of  skin,  the  surface  is  frequently 
sponged  with  cool  or  tepid  water.  A  combination  of  car- 
bonate of  potassa  and  acetated  tincture  of  opium,  with  fresh 
lemon-juice,  in  peppermint  or  camphor-water,  will  often  act 
like  a  charm  in  relieving  the  gastric  and  intestinal  irritability, 
the  cramps,  and  other  distressing  symptoms. 

The  exposure  of  the  soldier,  both  in  the  tent  and  on  the 
field,  renders  him  extremely  prone  to  rheumatism,  frequently 
attended  with  high  inflammatory  excitement  and  severe  pain. 
Such  an  attack  is  often  effectually  put  to  flight  if,  at  its  in- 
ception, it  be  treated  with  a  large  anodyne  and  diaphoretic 
mixture,  as  fifteen  grains  of  Dover's  powder,  a  third  to  half  a 
grain  of  sulphate  of  morphi,  with  a  fourth  of  a  grain  of  tartar 
emetic,  or,  what  is  perhaps  still  better,  a  drachm  of  the  wine 
of  colchicum  in  union  with  a  full  dose  of  morphia  or  black 
drop.  When  the  disease  has  already  made  some  progress, 
an  active  purgative  should  precede  the  exhibition  of  these 
medicines. 

Sore  throat,  tonsilitis,  and  catarrhal  affections,  or  what,  in 
common  language,  are  called  colds,  are  very  common  among 
soldiers,  especially  the  raw  troops  just  mustered  into  service, 
ill  clothed,  inexperienced,  and  unaccustomed"  to  camp  life. 
The  moment  such  disease  sets  in,  no  matter  how  light  it  may 
be,  the  person  should  be  compelled  to  report  himself  at  the 
surgeon's  quarters,  in  order  that  he  may  receive  the  necessary 
attention  and  advice.     Generally,  an  attack  of  this  kind  will 


MILITARY   SURGERY.  67 

promptly  yield  to  a  trifling  prescription,  as  a  little  hot  drink,  a 
mild  aperient,  or,  better  still,  a  quarter  of  a  grain  of  morphia, 
a  grain  of  opium,  or  a  large  dose  of  Dover's  powder. 

In  an  army  not  under  strict  discipline,  or  where  proper 
care  is  not  observed  in  enlisting,  mania  a  potu  is  very  apt  to 
show  itself,  much  to  the  annoyance  of  the  nurses  and  the 
physicians.  If,  in  such  a  case,  the  patient  be  not  well 
secured,  he  may,  in  his  perverted  military  ardor,  do  serious 
mischief  to  himself  and  to  his  attendants.  A  moderately 
active  mercurial  purge  at  the  outset  of  the  disease  will  often 
go  far  in  quieting  the  system  and  in  abridging  the  attack. 
After  the  medicine  has  operated,  a  mild  opiate  and  sedative 
treatment  will  generally  be  the  most  soothing.  Alcoholic 
stimulants  are,  in  general,  to  be  withheld. 

Nostalgia  is  another  complaint  liable  to  assail  the  soldier, 
even  the  hardiest,  especially  if  he  is  a  person  of  strong  do- 
mestic attachments,  or  engaged  in  an  "  affaire  du  coeur."  It 
is  more  apt  to  show  itself  in  soldiers  enlisting  for  the  foreign 
service,  or  in  those  who  are  forcibly  expatriated,  and  i?  often 
attended  with  great  suffering,  terminating  in  confirmed  melan- 
choly. It  is  characterized  by  a  love  of  solitude,  a  vacant, 
stultified  expression  of  the  countenance,  a  morose,  peevish 
disposition,  absence  of  mind,  pallor  of  the  cheeks,  and  pro- 
gressive emaciation.  Many  of  Bonaparte's  troops,  during  the 
campaign  in  Egypt,  suffered  from  this  complaint;  some  in  a 
very  distressing  degree.  In  this  country,  nostalgia  will  not 
be  likely  to  occur,  at  least  not  to  any  extent,  as  our  people  are 
essentially  of  a  roving  habit,  and  of  an  eminently  social  dispo- 
sition. The  treatment  is  rather  moral  than  medical ;  agreeable 
amusements,  kindness,  gentle  but  incessant  occupation,  and 
the  promise  of  an  early  return  to  home  and  friends,  consti- 
tuting the  most  important  means  of  relief. 

It  is  impossible,  even  under  the  most  rigid  discipline,  to 
prevent  gonorrhoea  among  soldiers.  They  will  expose  them- 
selves, in  spite  of  all  that  can  be  done  to  prevent  it,  and  they 
often  pay  a  heavy  penalty  for  their  indulgence,  not  only  from 


68  MILITARY   SURGERY. 

the  suifering  entailed  by  the  primary  disease,  but  its  different 
complications,  especially  chordee,  cystitis,  and  orchitis.  The 
symptorus  of  gonorrhoea  are  too  well  understood  to  require 
enumeration  here.  The  treatment  should,  from  the  start,  bo 
rigidly  antiphlogistic;  by  rest,  low  diet,  active  purgation,  and 
the  antimonial  and  saline  mixture,  with  the  addition  of  a 
small  quantity  of  copaiba.  The  penis  and  scrotum  are  well 
supported,  and  covered  with  warm  water-dressing,  the  former 
organ  being  bathed  in  tepid  salt  water,  at  least  thrice  daily, 
for  twenty  minutes  at  a  time.  When  the  discharge  is  greatly 
lessened,  but  not  till  then,  recourse  is  had  to  injections  of 
lead,  sulphate  of  zinc,  or  nitrate  of  silver,  at  first  very  mild 
and  gradually  increased  in  strength,  repeated  every  six,  eight 
or  twelve  hours.  The  treatment  is  continued,  in  a  modified 
form,  for  about  five  days  after  all  the  specific  symptoms  have 
vanished. 

Chordee  is  best  relieved  by  a  full  anodyne,  as  half  a  grain 
of  morphia,  in  union  with  the  fourth  of  a  grain  of  tartar 
emetic,  given  towards  bedtime,  or  by  a  large  enema  of  lauda- 
num ;  with  warm  water-dressings  to  the  genitals. 

For  the  relief  of  cystiiisj  the  most  appropriate  remedies 
are  anodyne  diaphoretics,  in  the  form  of  Dover's  powder, 
or  a  solution  of  morphia  and  tartar  emetic,  aided  by  the 
free  use  of  bicarbonate  of  soda  and  moderate  quantities  of 
diluents. 

Orchitis  is  treated  by  suspension  of  the  affected  organ,  with 
strong  lead  and  anodyne  lotions,  and  the  judicious  exhibition 
of  antimony,  in  union  with  morphia  or  black  drop. 

Chancres  must  be  thoroughly  cauterized  at  the  beginning, 
either  with  nitrate  of  silver,  nitric  acid,  or  acid  nitrate  of 
mercury;  and,  subsequently,  or  after  the  disease  has  made 
some  progre&s,  like  any  common  sore,  with  mild*  measures; 
mercury  being  studiously  withheld,  except  in  the  hard  form 
of  the  disease,  but  not  even  then  while  there  is  much  inflam- 
mation or  inordinate  constitutional  excitement.  In  a  word, 
all  harsh  measures  must  be  avoided.     The  patient  will  gene- 


MILITARY   SURGERY.  69 

rally  do  a  thousand  times  better  without  than  with  mercury. 
The  greatest  possible  attention  must  be  paid  to  cleanliness, 
and  for  this  purpose  the  parts  should  be  frequently  bathed  in 
tepid  salt  water,  aided  by  the  syringe  if  there  be  a  tight  pre- 
puce. The  best  local  application  is  the  warm  water-dressing, 
covering  in  the  entire  genitals;  if  much  swelling  and  pain  are 
present,  it  may  be  advantageously  medicated  with  lead  and 
opium.  As  the  inflammation  subsides,  the  sore  may  be 
dressed  with  some  gently  stimulating  lotion,  as  two  grains  of 
tannin,  the  eighth  of  a  grain  of  sulphate  of  copper,  and  half  a 
drachm  of  laudanum  to  the  ounce  of  water,  a  weak  mixture 
of  sherry  and  water,  or  a  solution  of  nitrate  of  silver,  zinc  or 
iodide  of  iron.  If  the  ulcer  is  disposed  to  spread,  or  presents 
a  sloughy  or  unhealthy  aspect,  it  will  be  proper  to  touch  it 
lightly  twice  a  day  with  the  solid  nitrate  of  silver,  or  a  solu- 
tion of  one  part  of  acid  nitrate  of  mercury  to  four  parts  of 
water. 

The  constitutional  treatment  is  rigidly  antiphlogistic,  or 
tonic  and  supporting,  according  to  the  particular  nature  of 
the  case.  The  bowels  should  receive  early  attention;  the 
skin  be  kept  moist;  and  pain  be  allayed  ty  anodynes.  Per- 
fect recumbency  should  be  observed  until  the  parts  are  nearly 
healed.  If  mercury  be  required,  the  best  forms  will  be  calo- 
mel and  blue  mass,  in  small  doses,  twice  a  day,  with  a  vigilant 
eye  to  their  effects,  ptyalism  being  studiously  avoided  in  every 
case. 

If  huho  supervene,  the  treatment  must  be  prompt  and 
efl&cieat,  with  a  view  to  the  prevention  of  further  mischief. 
Recumbency,  the  topical  use  of  iodine  with  warm  water- 
dressing,  medicated  with  lead  and  opium,  light  diet,  and  the 
antiraonial  and  saline  mixture,  constitute  the  most  appropriate 
measures.  If  matter  form,  an  early  and  free  incision  is  made, 
and  the  part  afterward  treated  as  a  common  sore,  the  granu- 
lating process  being  promoted  by  mild  means.  Mercury  is 
carefully  withheld,  at  all  events  in  the  early  stage  of  the 
disease. 


70  MILITARY   SURGERY. 

The  array  is  no  place  for  soldiers  laboring  under  secondary 
or  tertiary  syphilis ;  the  sooner  they  are  dismissed  from  the 
service  the  better,  especially  if  they  are  volunteers. 

Ophthalmia  is  one  of  the  annoyances  of  the  soldier's  life. 
Liable  to  be  caused  by  cold,  it  is  capable  of  assuming  several 
varieties  of  form,  and  sometimes  prevails  extensively  as  an 
epidemic.  The  granular  and  purulent,  in  particular,  are  to 
be  feared,  as  they  frequently  destroy  the  sight,  and  even  the 
eye,  in  a  few  days,  occasioning  intense  suifering.  To  ascer- 
tain the  condition  of  the  parts,  the  lids  must  always  be  gently 
everted  with  a  probe  or  the  finger.  The  greatest  cleanliness 
should  be  observed  in  these  affections  j  the  patient  should,  if 
possible,  be  sequestered,  at  all  events  not  be  permitted  to  use 
the  same  basins  and  towels  j  the  light  should  be  excluded  from 
the  apartment;  and  the  general  and  local  treatment  should 
either  be  strictly  antiphlogistic  or  of  a  mixed  character,  partly 
antiphlogistic  and  partly  stimulant.  The  applications  should 
be  of  the  mildest  description,  especially  those  intended  for 
the  inflamed  surface.  The  syringe  is  frequently  used  to  wash 
away  the  secretions.  Strong  collyria  generally  do  immense 
harm  in  all  forms  and  stages  of  ophthalmia.  Blood  may  be 
taken  from  the  arm,  or  by  cups  or  leeches  from  the  temples, 
if  the  symptoms  are  unusually  urgent,  and  the  patient  pleth- 
oric. In  rheumatic  inflammation  of  the  eye,  colchicum  and 
morphia,  given  freely  at  bed  time,  will  be  of  immense  service. 

When  foreign  matter  gets  into  the  eye,  or  becomes  imbed- 
ded in  the  cornea,  speedy  removal  must  be  efifected,  and  the 
parts  afterwards  treated  with  rest,  cold  or  tepid  bathing,  gentle 
aperients,  and  seclusion  from  light.  Particles  of  steel  and 
other  sharp  bodies  are  picked  out  with  the  point  of  a  delicate 
bistoury  or  cataract  needle.  The  efi"ects  of  lime  and  other' 
alkalies  are  neutralized  by  syringing  the  eye  freely  with  a 
weak  solution  of  vinegar;  those  of  nitrate  of  silver,  with  a 
weak  solution  of  common  salt,  a  thorough  coating  of  olive  oil 
being  afterward  applied. 

Carbuncles  J  boils/  and  abscesses,  which   are  of  frequent 


MILITARY   SURGERY.  71 

occurrence  in  army  practice,  demand  prompt  attention,  both 
on  account  of  the  sufifering  they  induce  and  the  disqualifica- 
tion they  may  entail  for  temporary  duty.  They  should  be 
opened  early  and  freely,  and  no  time  be  lost  in  amending  the 
general  health  by  gentle  mercurial  and  other  purgatives,  alter- 
ants, and  tonics,  particularly  quinine  and  iron.  The  most 
appropriate  remedies  are  tincture  of  iodine  and  warm  water- 
dressings. 

In  carbuncles  the  afi'ected  structures,  after  free  division, 
will  generally  require  the  thorough  application  of  some  escha- 
rotic  or  detergent  stimulant,  as  Vienna  paste,  nitric  acid, 
nitrate  of  silver,  or  acid  nitrate  of  mercury. 

Frost-hite  is  extremely  common  among  soldiers  during  the 
cold  wet  weather  of  winter.  Thousands  of  the  French  troops 
perished  from  this  cause  in  Eussia,  during  Napoleon's  retreat 
from  Moscow.  Frost-bite  was  very  prevalent  among  the 
English  during  their  first  winter  in  the  Crimea,  and  the 
French  suffered  in  still  greater  numbers,  as  well  as  more 
severely.  The  habit  which  the  men  had  .of  sleeping  in  their 
wet  boots,  at  one  time  almost  universal,  contributed  greatly  to 
its  production,  wet  and  cold  combined  diminishing  the  circu- 
lation and  vitality  of  the  feet  and  toes.  On  the  21st  of  Jan- 
uary, 1855,  when  the  thermometer  stood  at  5°,  not  less  than 
2500  cases  of  frost-bite  were  admitted  into  the  French  ambu- 
lance, and  of  these  800  died,  death  in  many  having  no  doubt 
been  expedited  by  the  effects  of  erysipelas,  pyemia,  and  hos- 
pital gangrene.  Weak  and  intemperate  persons  are  most  apt 
to  have  frost-bite  and  to  perish  from  its  effects. 

In  the  treatment,  in  incipent  cases,  cloths,  wrung  out  of 
cold  water  impregnated  with  a  little  spirits, of  camphor  or 
alcohol,  should  be  applied,  or  the  parts  be  covered  for  a  few 
minutes  with  snow,  or  immersed  in  cold  water.  On  no 
account  must  they  be  exposed  to  warmth,  either  moist  or 
dry.  Excessive  reaction  is  controlled  by  lead  and  laudanum 
lotions,  or  dilute  tincture  of  iodine.  If  gangrene  occurs,  the 
ordinary  measures,  local  and  general,  are  indicated.    All  rude 


72  MILITARY   SURGERY. 

manipulation  in  dressing  the  injured  part  greatly  aggravates 
the  disease.  In  general,  spontaneous  amputation  is  waited 
for,  experience  having  shown  that  operative  interference, 
even  when  the  part  is  perfectly  black,  and  attached  onl}^  by  a 
few  living  shreds,  is  extremely  prone  to  be  productive  of  ex- 
cessive pain  and  constitutional  irritation,  often  proceeding  to 
an  alarming  extent. 

Among  the  great  evils,  both  of  civil  and  military  practice, 
are  bed-sores,  which,  unless  the  greatest  possible  precaution  be 
used,  are  sure  to  arise  during  the  progress  of  acute  diseases 
and  of  severe  accidents,  necessitating  protracted  recumbency. 
The  hips  and  sacral  region  are  their  most  common  sites,  with 
the  heel  in  cases  of  fractures  of  the  leg.  The  earlier  symp- 
toms are  a  sense  of  prickling,  as  if  the  part  were  rubbed  with 
coarse  salt,  or  a  burning,  itching  or  smarting  pain,  with  a 
brownish  or  livid  discoloration  of  the  skin,  and  slight  swell- 
ing.    Then  gangrene  ensues,  followed  by  horrible  suffering. 

To  prevent  these  sores,  which  often  prove  destructive  to 
life,  when  there  is  already  much  exhaustion  from  previous 
suffering,  the  posterior  surface  of  the  body  should  be  fre- 
quently examined,  particularly  if  the  patient  is  in  a  state  of 
mental  torpor,  and  pains  taken  to  ward  off  pressure  by  the 
use  of  air  cushions  and  other  means.  The  parts  should  be 
sponged  several  tiuies  a  day  with  some  alcoholic  lotion  con- 
taining alum,  or  painted  with  a  weak  solution  of  iodine.  If 
gangrene  or  ulceration  occurs,  a  yeast  or  port  wine  poultice 
is  used,  the  separation  of  the  slough  is  aided  with  the  knife, 
while  the  granulating  process  is  promoted  by  the  usual 
remedies. 

Ulcers  of  the  leg  are  causes  of  disqualification  in  enlisting, 
but  they  sometimes  occur  after  the  soldier  has  entered  the 
service,  from  fatigue,  injury,  or  undue  constriction  of  the 
limb.  However  induced,  they  should  be  managed  as  any 
other  forms  of  inflammation,  recumbency  with  elevation  of 
the  affected  parts,  tepid  water-dressings,  a  restricted  diet,  and 
cooling  purgatives  constituting  the  most  important  elements 


MILITARY   SURGERr.  73 

of  the  treatment.  "When  the  healiug  process  has  fairly  com- 
jDcnced,  the  leg  should  be  supported  with  the  roller  or  adhe- 
sive strips. 

As  preventive  of  ulcers  of  the  legs,  the  limbs  should  be 
daily  washed  in  cold  water  with  Castile  soap,  and  no  soldier 
should  be  permitted  to  wear  garters. 


CHAPTER  X. 

MILITAPwY  HYGIENE. 

Much  disease  and  suffering  may  be  prevented,  and  many 
rlives  saved,  by  a  careful  observance  of  hygienic  regulations, 
r  There  is  no  question  whatever  that  immense  numbers  of 
soldiers  everywhere  fall  victims  to  their  recklessness  ahd  the 
indulgence  of  their  appetites  and  passions.  We  would  not 
advocate  too  much  restraint;  men  are  but  men  everywhere, 
and  soldiers  form  no  exception  to  the  general  law.  They, 
like  civilians,  must  have  their  amusements  and  recreations. 
The  bow  cannot  last  long,  if  kept  too  constantly  and  too 
tightly  on  the  stretch.  Occasional  relaxation  is  indispensable 
to  hiyilth. 

Indolence,  however,  should  never  be  countenanced  in  any 
army.  Its  demoralizing  effects,  and  its  influence  upon  the 
health  of  the  soldier,  have  been  noticed  and  commented  upon 
in  all  ages.  "The  efl&cacy,"  says  an  eminent  military  sur- 
geon, in  speaking  on  this  subject,  "  of  due  attention  to  the 
occupation  of  the  mind  must  never  be  lost  sight  of.  Many 
illustrations  of  its  powerful  influence,  whfther  for  good  or 
evil,  whether  in  resisting  or  accelerating  the  inroads  of  dis- 
ease, may  be  found  both  in  ancient  and  in  modern  times,  from 
the  retreat  ot  the  ten  thousand  Greeks  under  Xenophon  down 
to  the  present  day.  It  may  be  observed,  that  disease  goes 
hand  in  hand  with  indolence  and  inactivity,  whether  of  body 
4 


74  ,  MILITARY   SURGERY. 

or  of  mind ;  and  that,  on  the  contrary,  where  the  minds  of 
soldiers  are  agreeably  occupied,  and  their  bodies  energetically 
employed,  as  in  the  attainment  or  pursuit  of  victory,  disease 
is  kept  in  abeyance."  It  was  the  observation  of  another  ex- 
perienced authority  in  military  medical  affairs,  Mr.  Alcock^ 
that,  "  the  period  of  the  smallest  loss  to  an  army  is  a  victo- 
rious and  vigorously  prosecuted  campaign,  with  frequent  bat- 
tles and  much  marching;"  an  assertion  corroborative  of  the 
f\\cts,  long  since  so  painfully  realized,  that  sickness,  however 
induced,  destroys  incomparably  more  soldiers  than  the  sword 
and  the  musket. 

No  intemperance,  either  in  eating  or  drinking,  should  bo 
tolerated  in  an  army;  both  are  demoralizing,  and  both  pre'dis- 
pose  to,  if  not  actually  provoke,  disease.  Alcoholic  liquors, 
should  not  be  permitted  to  be  used  except  as  medicine,  and 
then  only  under  the  immediate  direction  (»f  the  medical  officer. 
The  ordinary  drink  and  food  should  be  selected  with  special 
reference  to  their  healthful  -properties.  The  use  of  bad  water, 
even  for  a  short  time,  is  invariably  productive  of  mischief. 
The  tea  and  coffee,  should  be  of  good  quality,  and  well  pre- 
pared, to  preserve  their  agreeable  flavor  and  their  soothing 
and  refreshing  effects.  Ledger  beer,  ale,  and  porter,  if  sound, 
are  both  nourishing  and  wholesome,  if  consumed  within  judi- 
cious limits. 

The  practice  of  allowing  soldiers  spirituous  liquors,  as  a 
portion  of  their  daily  rations,  has,  I  believe,  been  pretty 
generally,  if  not  entirely,  abandoned  in  the  European  service. 
Its  injuririus  effects  upon  the  health  and  morals  of  troops  have 
long  been  deprecated.  In  the  British  army  in  India,  the  use 
of  alcoholic  liquors  was,  at  one  time,  universal,  on  the  suppo- 
sition that  it  ha#  a  tendency  to  counteract  the  depressing 
influences  of  a  tropical  climate;  the  men  took  their  spirits 
regularly  before  breakfast,  and  not  unfrequently  several  times 
during  the  day,  especially  if  on  active  duty;  but  it  was  soon 
found  that  it  produced  quite  a  contrary  impression,  causing 
instead  of  preveatiDg  debility,  and  affording  a  temptation  to 


MILITARY   SURGERY.  75 

general  drunkenness,  which  was  followed  by  insubordination 
and  crime.  The  result  was,  that  the  government  aboHshed 
the  alcoholic  ration  system  altogether,  substituting  coffee  and 
tea,  which  are  now  regularly  served  once,  and  often  twice  a 
day. 

Th«  condition  of  the  13th  Regiment  of  Light  Infantry, 
stationed  at  Jellalabad,  during  the  late  insurrection  in  India, 
affords  a  happy  illustration  of  the  salutary  effects  of  absti- 
nence from  spirituous  liquors.-  While  the  siege  was  progress- 
ing, the  men,  during  a  period  of  five  months,  were  entirely 
debarred  from  drinking,  and  yet  their  health  and  courage 
were  most  excellent.  As  soon,  however,  as  the  garrison  was 
relieved,  and  they  began  to  indulge  in  spirits,  many  of  them 
in  a  short  time  became  sick  and  riotous.  The  experience  of 
Major-Gcneral  Wylie,  of  the  Bombay  army,  was  precisely  simi- 
lar. When  the  soldiers  under  his  command  were  quartered 
in  districts  where  no  liquor  could  be  obtained,  their  health, 
discipline  and  morals  were  all  that  could  be  desired  ;  whereas, 
under  opposite  circumstances,  insubordination  and  disease 
prevailed  to  a  frightful  extent. 

During:  the  Crimean  war,  coffee  and  tea  were  found  to  be 
eminently  wholesome  and  invigoratii%,  enabling  the  troops  to 
sustain  fatigue  and  resist  disease.  When  the  men  were  in  the 
trenches,  and  could  not  obtain  their  usual  supply  of  these 
articles,  they  became  languid,  and  suffered  from  dysentery  and 
diarrhoea.  To  produce  their  peculiar  sustaining  and  exhilara- 
ting effects,  coffee  and  tea  should  be  taken  hot  and  moderately 
strong,  with  sugar,  if  not  also  with  cream. 

Fresh  meats  are  always  preferable  to  salt,  though  good  ham 
and  smoked  beef  may  be  taken  once  a  day  with  advantage 
as  an  agreeable  change.  Fresh  fish  are  always  acceptable. 
Pickled  pork  and  beef  are  far  from  being  good  articles  as  a 
portion  of  the  daily  rations.  The  frequent  use  of  fresh  vege- 
tables is  indispensable  to  the  health  of  the  soldiery.  Ripe 
fruits  are  nearly  equally  so.  Without  a  proper  admixture  of 
this  kind,   dyspepsia,   bowel   complaints,   and    acurvy   will, 


76  MILITARY   SURGERY. 

sooner  or  later,  inevitably  ensue;  and  woe  to  tlie  man  that  is 
assailed  by  them  !  The  acids  and  other  properties  contained 
in  these  substances  are  indispensable  to  the  healthy  condition 
of  tbe  blood  and  solids,  and  the  importance  of  such  a  diet 
cannot  be  too  deeply  or  too  frequently  impressed  upon  the 
attention  of  every  commissariat.  Potatoes,  rice,  hotniny, 
beans,  peas,  beets,  spinach,  lettuce,  asparagus,  radishes,  horse- 
radish, water-cresses,  dried  peaches  and  apples,  and  the  dif- 
ferent kinds  of  fruits  as  they  come  into  season,  should  be  con- 
stantly on  hand.  Soups,  both  animal  and  vegetable,  are 
generally  grateful  to  the  palate,  as  well  as  useful  to  the  sys- 
tem, and  should  be  used  whenever  the  occasion  is  favorable 
for  their  preparation. 

Eggs,  butter,  milk  and  butter-milk  should  be  freely  in- 
dulged in  whenever  they  can  be  procured.  Serious  disease 
is  often  engendered  by  bad  bread  and  biscuit,  and  it  should 
therefore  be  made  a^part  of  the  duty  of  every  medical  ofl&cer 
to  see  that  no  articles  of  this  kind  are  brought  into  camp. 

When  in  tbe  camp  or  barracks,  the  soldier  should  take  his 
meals  with  tbe  same  regularity  as  tbe  ordinary  citizen  at  his 
home.  Neglect  of  this  precaution  must  necessarily  lead  to 
great  bodily  incouvenieiJce,  and,  if  long  persisted  in,  may 
ultimately  lead  to  serious  disease,  especially  dyspepsia  and 
other  disorders  of  the  digestive  apparatus.  He  should  not  dis- 
regard regularity  even  with  respect  to  his  alvine  evacuations; 
for  there  are  few  things  more  conducive  to  tbe  preservation  of 
the  health. 

The  soldier's  dress  should  be  in  strict  conformity  with  the 
season  of  the  year  and  the  vicissitudes  of  the  weather.  He 
should  at  no  time,  be  either  too  hot  or  too  cold,  but  always 
comfortable,  changing  his  apparel  with  the  alterations  of  the 
temperature.  Flannel  should  be  worn  next  the  surface  both 
winter  and  summer.  Tbe  shoes  must  be  thick  and  warm, 
with  broad  soles;  and  woolen  stockings  will  be  more  comfort- 
able, especially  when  the  troops  are  marching,  than  cotton. 
A  thiu  woolen  cap-cover,  found  go  useful  in  India,  will  pro- 


MILITARY   SURGERY.  77 

tect  the  neck  from  the  hot  sun,  and  an  oil-silk  cap-cov^r,  from 
the  rain.  In  very  wet  weather  the  shoulders  might  be  de- 
fended with  a  cape  of  oil-cloth. 

Frequent  ahlutions  will  largely  contribute  to  the  comfort 
of  the  soldier  and  the  preservation  of  his  health.  They 
should  be  performed  at  least  once  a  day,  the  best  time  being 
late  in  the  afternoon  or  in  the  evening  just  before  retiring. 
The  feet,  in  particular,  should  be  often  washed,  especially  in 
marching,  for  reasons  which  need  not  be  dwelt  upon  here. 
The  under-shirt  should  be  changed  every  night,  and  frequently 
washed,  to  promote  the  healthy  state  of  the  skin. 

Exposure  to  the  hot  snn,  to  cold  and  wet,  must  alike  be 
avoided.  Sojourning  in  malarious  regions,  will  be  certain  to 
be  punished  by  an  attack  of  neuralgia  or  intermittent  fever. 

All  offah  should  be  promptly  removed  from  the  camp,  and 
carried  to  a  distance  of  several  miles,  or  be  well  buried. 

The  privies  should  be  in  the  most  favorabb  location  as  it 
respects  ventilation,  and  be  closed  at  least  every  thre3  or  four 
days;  or.  what  is  worthy  of  consideration,  every  man  should 
be  compelled  to  bury  his  alvine  excretions,  as  was  the  custom, 
in  time  of  war,  among  the  ancient  Hebrews,  each  man  being 
obliged  to,  carry  a  paddle  for  that  purpose  The  emanations 
from  these  sources  cannot  receive  too  much  attention,  espe- 
cially when  large  masses  of  men  are  crowded  together,  as 
they  are  then  extremely  prone  lo  induce  disease. 

Finally  the  medical  officer  should  make  'it  his  special  duty 
to  see  that  every  recruit  is  vaccinaled,  or,  if  the  operation  was 
performed  prior  to  his  enlistment,  at  a  distant  period,  matter 
should  again  be  inserted,  experience  having  shown  that  the 
effects  of  the  virus  are,  in  time,  in  many  instances,  totally 
eradicated  from  the  system.  In  most  of  the  European  armies 
re-vaccination  is  extensively  practiced ;  and  it  is  asserted  by 
Stromeyer  that  during  the  Schleswig-IIolstcin  war,  on  an 
average,  38  operations  out  of  1,000  were  successful. 

It  is  impossible  to  bestow  too  much  care  and  attention  upon 
the  selection  of  the  camp  ground,  and  the  arrangement  of  the 


78  MILITARY   SURGERY. 

tents,  a§  a  vast  deal  of  the  comfort  and  health  of  the  soldiers 
must  necessarily  depend  upon  them.  The  following  judicious 
remarks  upon  this  subject  are  from  the  pen  of  an  eminent 
military  surgeon,  the  late  Dr.  Ballingall,  who  served  in  vari- 
ous campaigns,  and  who  was  for  many  years,  as  stated  else- 
where. Professor  of  Military  Surgery  in  the  University  of 
Edinburgh. 

"  A  camp,"  says  Ballingall,  "  is  most  advantageously  situ- 
ated on  a  gentle  declivity,  on  a  dry  soil,  and  in  the  vicinity 
of  a  running  stream.  In  order  to  ascertain  the  state  of  the 
ground  it  may  sometimes  be  necessary  to  dig  into  it  to  some 
extent;  for,  although  apparently  dry  on  the  surface,  it  may 
be  found  sufficiently  wet  at  the  depth  of  a  few  feet;  and  if 
so,  ought,  if  possible,  to  be  changed,  particularly  if  an  en- 
campment is  to  be  stationary.  A  camp  should  never  be 
formed  on  ground  recently  occupied,  nor  on  a  field  of  battle 
"where  much  carnage  has  recently  occurred.  Many  favorable 
spots  are  to  be  found  on  banks  of  rivers,  which,  perhaps,  upon 
the  whole,  afi'ord  the  most  eligible  sites.  We  must  yet  bear 
in  mind  that,  when  the  banks  of  the  rivers  are  low,  or  the 
country  subject  to  periodical  rains  or  sudden  inundations  from 
the  melting  of  snow  on  contiguous  mountains,  there  may  be  a 
very  serious  danger  from  this  cause.  Against  the  danger  of 
such  a  position,  we  are  cautioned  in  Mezerey's  *  Medecine 
d'Armee,'  which  states  a  case  in  which  the  Austrian  army  lost 
500  men  and  200  horses  from  a  sudden  inundati6n  of  this 
kind.'' 

When  damp  ground  or  a  low  situation  is  unavoidable,  it 
should  be  abandoned  as  soon  as  possible,  for  a  better,  and,  in 
the  meantime  the  greatest  care  should  be  taken  to  protect  the 
soldiers  from  damp  or  wet  with  straw  or  other  suitable  means. 

An  army  has  been  known  to  suiFer  severely  from  disease 
contracted  in  a  malarious  region.  Against  such  a  calamity 
useful  information  may  often  be  elicited  from  the  people  of 
the  neighborhood^  especially  physicians  conversant  with  insalu- 
brious sites. 


MILITARY   SURGERY.  79 

When  an  army  is  obliged  to  remain  for  a  long  time  station- 
ary, an  occasiona!  change  of  camp  will  be  greaily  condacive 
to  health,  although  such  change  should  involve  a  good  deal  of 
labor  and  temporary  inconvenience.  A  camp  under  such  cir- 
'cumstanccs  sliould,  at  all  eventf*,  be  frcquontly  ventilated,  and 
kept  constantly  clean,  a  pure  atmosphere  being  of  paramount 
importance  to  health  and  comfort  It  vxioy  often  be  difl5cult 
to  do  this,  but  it  must,  nevertheless,  be  done;  the  welfare  of 
the  service  absolutely  demands  it,  and  no  medical  officer  hon- 
estly perftirujs  hi^  duty  unless  he  inrer-.sts  himself  p  rsciuilly 
in  these  matters  "  The  most  obvious  and  per'ect  way,"  says 
Ballingall,  *' of  thoroughly  airing  the  tents  is  by  shifting 
them  oci-asioually,  and  exposing  the  straw,  blankets  and  sol- 
dier's clothing  to  the  open  air;  the  necessity  of  frequently 
changing  the  straw,  and  enforcing  cleanliness  in  camp,  in 
every  possible  way,  arc  circunist^inces  too  obvious  to  require 
any  effort  of  reasoning  to  enforce.  With  this  view  the  slaugh- 
tering of  cattle,  and  everything  likely  to  create  noxious  or 
putrid  effluvia,  ought  to  be  conducted  without  the  camp,  and 
on  the  side  of  it  opposite  to  that  from  which  the  wind  gene- 
rally blows."  The  demoralizing  influence  of  a  camp  life  is 
well  known,  and  I  am  convinced  that  there  is  nothing  so  well 
calculated  to  counteract  this  influence  as  rigid  discipline, 
reasonable  activity  of  tnind  and  body,  strict  temperance,  both 
in  eating  and  drinking,  and  frequent  religious  worship.  Every 
regiment  should  have  its  chaplains,  not  less  than  its  medi- 
cal officers,  not  only  with  a  view  of  restraining  vice  and  pro- 
moting morality,  but  of  affording  to  the  poor  soldier,  away 
from  home  and  friends,  in  the  hour  of  his  mortal  extremity, 
those  consolations  which  the  U)inister  of  the  gospel  alone 
knows  how  to  impart.  The  mitigation  of  the  horrors  and 
miseries  of  war,  not  less  than  the  tendencies  of  the  ac;e  in 
which  we  live,  absolutely  demand  such  a  provision. 


80  MILITARY   SURGERY. 

CHAPTER  XI. 

DISQUALIFYING  DISEASES. 

Troops,  "whether  regulars  or  volunteers,  should  include  no 
men  that  are  not  perfectly  qualified,  both  physically  and  men- 
tally, for  the  hardships  of  the  public  service.  They  should, 
in  a  word,  be  perfectly  sound,  or,  what  is  the  same  thing,  free 
from  all  defects,  congenital  or  acquired.  It^is  for  this  reason 
that  they  are  always  subjected  to  a  most  thorough  examina- 
tion by  the  recruiting  or  regimental  surgeon.  This  examination 
is,  as  a  general  rule,  a  great  deal  more  rigid  in  the  regular 
than  in  the  volunteer  service.  In  the  former,  the  regulations 
are  such  that,  if  the  recruit  is  not  found  to  be  sound  after  he 
has  been  inspected  by  the  regular  army  surgeon,  the  expense 
incident  to  his  enlistment  and  transportation  fiills  upon  the 
medical  officer  who  committed  the  oversight. 

An  examination  of  the  kind  here  mentioned  demands  both 
time,  patience  «ind  skill.  In  order  to  make  it  thorough,  the 
candidate  must  be  completely  stripped,  so  that  if  any  disease 
or  defect  in  the  exterior  of  the  body  exist,  it  may  be  at  once 
rendered  apparent.  The  examination,  however,  must  not  be 
limited  to  the  exterior ;  it  must  embrace  also  the  interior. 
The  disqualifying  affections  may  be  arranged  according  to  the 
organs  and  regions  in  which-  they  are  seated,  under  separate 
heads : — 

1.  The  eye  and  ear.  2.  The  brain,  as  the  seat  of  intellect. 
3.  The  lungs  and  heart.  4.  The  stomach,  bowels,  anus,  liver 
and  spleen.  5.  The  kidneys,  bladder  and  urethra.  6.  The 
testicles.  7.  The  exterior  of  the  abdomen.  8.  The  limbs, 
including  the  joints. 

The  diseases  which  unfit  a  man  for  military  service  are  de- 
fects of  sight,  of  hearing,  and  of  speech;  weakness  of  intel- 
lect; paralysis;  epilepsy;  hernia;  hydrocele;  varicocele; 
imperfect  development  or  absence  of  the  testes ;  hemorrhoids, 


MILITART  StJRaERY.  81" 

anal  fistule,  and  fissure  of  the  anus ;  unusual  protuberance  of 
the  abdomen;  organic  lesion  of  the  internal  organs;  large 
tumors;  aneurism;  varix  of  the  extremities;  ulcers,  or  large 
scars  indicative  of  their  former  existence;  bad  corns,  bunions; 
overlapping  toes;  flatfootedness;  deformity  of  the  hands  and 
fingers;  contractions  from  burns  or  other  causes;  badly  united 
fractures;  unreduced  dislocations;  diseased  joints;  loss  of 
the  incisor  and  canine  teeth;  serious  disfigurement  of  the  fea- 
tures; spinal  curvature;  ill-formed  shoulders;  habits  of  in- 
temperance ;  diminutive  stature  or  excessive  overgrowth. 

In  the  regular  army  no  man  is  enlisted  under  the  age  of 
eighteen  or  over  that  of  forty-five.  In  the  volunteer  service, 
similar  regulations  obtain,  although  they  are  not  so  rigidly 
enforced. 

Kecruiting  surgeons,  after  having  examined  a  candidate  for 
enlistment,  are  obliged  to  certify,  oq  honor,  that  they  consider 
him,  in  their  opinion,  to  be  free  from  all  bodily  defect^  and 
mental  infirmity,  which  would,  in  any  way,  disqualify  him  for 
performing  the  duties  of  a  soldier. 

When  men  become  disqualified  for  service,  in  consequence 
of  disease  or  accident,  a  surgeon's  certificate  is  also  required, 
in  order  to  aid  them  afterward  in  procuring  a  pension  and  ex- 
emptijn  from  ordinary  military  duties.  The  afi*ections  which 
may  justify  a  soldier  in  applying  for  a  release  from  further 
service,  are  organic  visceral  lesions,  deafness,  blindness,  men- 
tal imbecility,  lameness,  large  hernias,  and  such  mutilations  as 
interfere  with  the  proper  handling  of  the  sword  and  musket. 


CHAPTER  XII. 

FEIGNED  DISEASES. 

Soldiers,  influenced  by  a  desire  to  quit  the  service,  to  re- 
visit their  homes,  or  evade  active  duty,  will  not  hesitate,  at 
times,  to  play  the  part  of  impostors,  feigning  diseases,  or  even 


82  •      MILITARY  SURaERY. 

inflicting  upon  themselves  more  or  less  serious  injuries,  with 
the  hope  of  accomplishing  their  designs.  This  deception, 
technically  called  malingering,  would  be  of  comparatively  lit- 
tle consequence  if  it  were  always,  or  even  generally,  confined 
to  a  few  members  of  a  regiment;  but  when  it  is  remembered 
that  it  is  liable  to  become  epidemic,  spreading  from  individual 
to  individual,  it  assumes  a  deep  importance,  well  calculated,  to 
arouse  the  attention  both  of  the  medical  ofl&cer  and  of  the 
military  commander.  Its  effects,  then,  become  eminently 
demoralizing  to  the  service,  which,  if  proper  care  be  not  em- 
ployed to  detect  and  punish  it,  might  seriously  suffer,  espe- 
cially when  such  an  outbreak  occurs  on  the  eve  of  a  battle. 
Great  ingenuity  is  often  displayed  by  malingerers,  requiring 
no  little  vigilance  and  skill  on  the  part  of  the  surgeon  for  its 
successful  exposure,  and  yet  it  is  not  less  necessary  for  his  own 
credit  than  for  the  honor  of  the 'service  that  he  should  not 
permit  himself  to  be  deceived. 

The  number  of  diseases  imitated  by  this  class  of  dissem- 
blers, is  surprisingly  great,  and  there  is  also  quite  a  list  of 
self-inflicted  injuries.  Among  the  former  are  various  mental 
diseases,  as  mania  and  imbecility;  deafness;  amaurosis;  epi- 
lepsy; paralysis;  hsematemcsis;  haeinoptysis;  gastritis;  dys- 
entery and  diarrhoea;  affections  of  the  heart;  rheumatism; 
lumbago;  wry-neck;  contractions  of  the  joints ;  incontinence 
of  urine;  bloody  urine;  and  stone  in  the  bladder:  among 
the  latter,  opthalmia,  opacity  of  the  cornea,  oedema  of  the 
limits,  wounds,  and  amputations  of  the  fingers. 

Space  will  not  permit  me  to  enter  into  any  details  respect- 
ing this  important  subject.  I  shall,  therefore,  content  myself 
with  a  presentation  of  such  facts  as  may  be  supposed  to  be  of 
special  practical  interest. 

First  of  all,  the  medical  officer  should  weigh  well  in  his 
own  mind  the  nature  of  the  disease  for  which  a  soldier  applies 
f  >r  a  certificate  of  discharge,  or  inability  to  perform  duty.  If 
the  case  is  one  of  recent  standing,  it  will  be  well  not  to  come 
to  too  hasty  a  conclusion  as  to  its  diagnosis;  it  should  be  ex- 


MILITARt  SXTRQERT*  83 

amined  and  re-examined  before  any  definite  opinion  is  given. 
Day  by  day  facts  may  be  developtd  revealing  the  tru^ charac- 
ter of  the  affection.  If  the  patient  is  really  sick,  or  affected 
with  some  serious  chronic  disorder,  his  general  appearance 
•will  hardly  fail  to  afford  some  evidence  of  its  existence.  The 
pallor  of  the  countenance,  the  functional  disturbance  of  the 
suffering  organ,  the  bodily  prostration,  the  want  of  appetite, 
and  the  gradual  emaciation,  will  almost  unerringly  poiut  to 
the  nature  and  seat  of  the  disease.  When,  on  the  other 
hand,  the  malady  is  simulated,  all,  or  nearly  all,  the  usual 
phenomena  of  disease  will  be  absent.  Impostors,  moreover, 
are  generally  very  zealous  in  talking  about  their  disorders,  or 
in  obtruding  them  upon  the  notice  of  their  surgeons ;  where- 
as those  who  are  really  sick  and  suffering  make  comparatively 
little  complaint.  A  malingerer  may  often  be  detected  by 
carefully  watching  his  movements,  coiring  suddenly  upon  him 
when  he  is  asleep,  or  when  his  attention  is  directed  to  some 
one  else,  tickling  his  foot  when  he  feigns  paralysis,  or  prick- 
ing his  back  when  he  pretends  to  be  laboring  under  lumbago. 
Sometimes  a  determined  threat  will  promptly  restore  him  to  a 
sense  of  his  duty,  as  the  application  of  the  actual  cautery  in 
incontinence  of  urine,  rheumatism  of  the  joints,  or  mental 
imbecility.  Now  and  then  the  exhibition,  in  rapidly  repeated 
doses,  of  a  nauseous  draught,  answers  the  purpose.  What- 
ever expedients  be  employed,  the  surgeon  cannot  exercise  too 
much  address,  otherwise  he  will  be  almost  sure  to  be  baffled. 

Mental  alienation,  or  mania j  unless  the  result  of  inebria- 
tion and  of  acute  disease,  generally  comes  on  gradually,  being 
prefjeded  by  a  marked  chanf];e  in  the  moral  character  of  the 
individual,  loss  of  appetite  and  sleep,  and  other  evidences  of 
general  disorder. 

Genuine  deafness  is  also  gradual  in  its  approaches,  and, 
when  fully  established,  is  invariably  attended  by  a  peculiar 
listless  state  of  the  countenance  with  more  or  less  change  of 
the  voice.  Before  a  final  decision  is  given,  a  careful  inspec- 
tion of  the  ears  should  be  made,  to  ascertain  whether  there  is 


84:  MILITARY  SURGERY.: 

any  obstruction  or  appearance  of  matter.  The  unexpected 
discharge  of  a  pistol,  in  a  case  of  feigned'  deafness,  might 
suddenly  decide  the  diagnosis. 

Amaurosis  may  be  simulated  by  the  internal  use  of  bella- 
donna, or  by  the  direct  application  of  this  article  to  the  eye, 
causing  dilatation  and  immobility  of  the  pupil.  These  effects 
are  often  accompanied  by  unnatural  vascularity  of  the  con- 
junctiva, and  they  generally  disappear  spontaneously  in  a  few 
days.  In  genuine  amaurosis,  too,  there  is  always  a  dilated 
condition  of  the  vessels  of  the  eye. 

Feigned  epilepsy  differs  from  the  real  in  the  absence  of 
lividity  of  the  countenance,  the  want  of  froth  at  the  mouth, 
and  the  partial  character  of  the  convulsions.  The  pupil  does 
not  contract,  as  in  the  genuine  disease,  the  general  sensibility 
is  unimpaired,  the  tongue  is  not  injured,  the  nails  are  not  dis- 
colored, the  hand,  if  opened,  is  again  firmly  shut,  and  the  in- 
dividual often  watches  with  his  eye  the  impression  the  attack 
is  making  upon  the  by-standers.  The  application  of  a  heated 
case  knife,  or  of  a  cloth  wrung  out  of  hot  water,  often  speed- 
ily reveals  the  imposition. 

Paralysis  is  frequently  imitated,  but  is  generally  easily  de- 
tected, simply  by  watching  the  patient,  tickling  his  feet  when 
he  is  asleep,  or  threatening  him  with  the  hot  iron.  The  dis- 
ease, when  it  attacks  the  lower  extremity,  is  nearly  always 
caused  by  apoplexy,  and  is  then  generally  associated  with 
mental  weakness  and  difficulty  of  articulation.  Partial  par- 
alysis of  the  upper  extremity  is  frequently  induced  by  lying 
upon  the  arm,  by  suppression  of  the  cutaneous  perspiration, 
"and  disease  of  the  spinal  cord. 

Hdemet  inesis  may  be  simulated  by  swallowing  blood,  or  an 
infusion  of  logwood,  and  ejecting  the  fluid  afterward  by  vomit- 
ing. It  should  be  recollected  that  the  real  disease  is  almost 
invariably  connected  with  serious  organic  lesion,  as  ulceration 
of  the  stomach,  induration  and  enlargement  of  the  liver,  or 
visceral  obstruction,  and  that  the  patient,  consequently,  will 
exhibit  all  the  characteristics  of  a  sick  person. 


MilitAey  surgery.  85 

Soldiers  sometimes  counterfeit  haemopft/siSy  by  cutting  the 
gums,  or  chewing  substances  impregnated  with  coloring  mat- 
ter. A  case  is  related  by  Guthrie,  in  which  a  man,  forthis 
purpose,  swallowed  a  piece  of  cork  full  of  pins.  The  imme- 
diate effect  was  haemoptysis,  and  the  remote  one  death,  by 
"wounding  the  carotid  artery. 

Gastritis  may  be  simulated  by  spontaneous  vomiting,  a 
faculty  possessed  by  some  persons,  aod  by  pretended  pain  in 
the  epigastric  region.  The  attack  in  general  speedily  yields 
to  a  large  sinapistn  and  a  brisk  emetic. 

Dysentery  and  diarrhoea  are  occasionally  feigned  by  excit- 
ing, artificially,  irritation  of  the  rectum,  by  mixing  blood  with 
the  alvine  evacuations,  or  by  borrowing  the  discharges  of  per- 
sons actually  affected  with  these  diseases.  In  genuine  dysen- 
tery and  diarrhoea  there  ate  always  well-marked  constitutional 
phenomena,  which  are  of  course  absent  in  the  spurious. 
Careful  watching  of  the  patient,  and  compelling  him  to  use 
a  close  stool,  will  soon  remove  any  doubt  that  may  exist  re- 
specting the  nature  of  the  case. 

Disease  qf  the  heart,  in  the  form  of  palpitation,  may,  it  is 
said,  be  produced  by  the  use  of  hellebore.  Mr.  Hutchinson, 
of  England,  refers  to  an  epidemic  of  this  kind  among  the 
members  of  the  Marine  Artillery.  Organic  cardiac  disease 
could  easily  be  detected  with  the  stethoscope. 

Rheumatism  being  a  very  common  disease  among  soldiers, 
is  often  counterfeited;  but  the  cheat  is  of  easy  detection  when 
it  is  recollected  that  the  real  affection,  especially  the  acute 
form,  is  attended  with  more  or  less  swelling  and  constitutional 
disturbance. 

When  lumbago  is  made  the  subject  of  deception,  the  attack 
seldom  hmg  withstands  the  application  of  fash  remedies,  or 
the  threatened  use,  if  speedy  relief  do  not  arise,  of  the  hot 
iron. 

Contraction  of  the  joints,  a  not  unfrequent  source  of  impo- 
sition, is  easily  detected  by  the  use  of  anaesthetics,  pr  simply 


^  JIILITART  SURGERT. 

by  pricking  the  parts  suddenly  with  a  needle,  when  the  pa- 
tient is  oif  his  guard. 

W'hen  wry-neck  is  simulated,  both  the  sterno-cleido-mas- 
toid  muscles  are  rendered  rigid  by  the  effort  at  deception ; 
whereas  in  the  real  disease  the  contraction  is  confined  to  one 
side. 

Incontinence  of  wnne,  bloody  urine,  and  stone  in  the  blad- 
der, have  all  been  simulated  by  designing  soldiers.  The 
former  is  said  to  be  at  times  epidemic,  and  then  its  detection 
is  of  course  easy,  as  the  ordinary  disease  never  assumes  such 
a  character.  Harsh  remedies  are  the  best  means  of  relief. 
Eallingall  states  that  fictitious  cases  of  incontinence  have  been 
successfully  treated  by  the  cold  bath,  by  prescribing  a  few 
lashes  on  the  loins,  with  the  avowed  object  of  strengthening 
the  parts.  In  the  Austrian  army  the  imposter  is  obliged  to 
do  duty  with  a  urinal. 

Bloody  urine  has  been  provoked  by  injecting  blood  into  the 
bladder,  and  by  scarifying  the  urethra. 

Calculus  is  almost  unknown  among  «oldicrs;  it  is  some- 
times attempted  to  be  counterfeited  by  scraping  tl^  walls  and 
throwing  the  lime  into  the  urinal.  When  stone  actually  ex- 
ists, the  sound  will  generally  promptly  detect  it. 

Self-inflicted  injuries  of  various  kinds  are  resorted  to  for 
the  purpose  of  deception.  Thus  malingerers  often  provoke 
inflammation  of  the  eye  and  temporary  opacity  of  the  cornea 
by  means  of  corrosive  sublimate,  lime,  tobacco,  nitrate  of  sil- 
ver, and  other  irritants.  A  great  number  of  men  have  been 
known  to  sufl'er  from  this  cause  at  the  same  time,  as  if  th<^s 
disease  was  an  epidemic.  Ulcers  of  the  legs  are  produced  by 
pricking  the  skin  with  pins  or  needles,  frictions  with  sand,  or 
caustic  applications.  (Edema  of  the  liuibs  may  be  excited  by 
tight  ligatures;  disease  of  the  scrotum  and  testicle,  by  infla- 
tion of  the  parts  with  air.  All  such  tricks  are  usually  readily 
detected  by  the  medical  ofiicer  and  1^  assistants. 

Self-mutilation  sometimes  amounts  to  the  destruction  of  an 
eye,  an  entire  finger,  or  even  the  greater  portion  of  the  hand. 


MILITARY  SURGERY.  87 

Occasionally  it  is  limited  to  slight  wounds,  and  the  imposition 
maj  then  be  practiced  on  an  extensive  scale,  as  was  the  case 
in  the  French  army  at  the  battles  of  Lutzen  and  Bautzen,  in 
which  nearly  3000  soldiers  were  slightly  injured  in  the  hand, 
causing  the  belief  that  the  wounds  had  been  voluntarily  in- 
flicted. 


CHAPTER   Xlir. 
MEDICAL,  SURGICAL  AND  DIETETIC  FORMULA. 

Under  this  head  I  propose  to  notice  such  formulae;  or  medi-^ 
cal,  surgical,  and  dietetic  preparations,  as  have  been  found 
serviceable  in  my  own  practice,  or  in  the  practice  of  others. 

1. —  General  Remedies. 

Among  the  more  simple  jmrf/a fives  may  be  mentionpd  the 
fol'owing:  nil  drastic  articles  should,  if  possible,  be  excluded 
from  the  prescriptions  of  the  military  surgeon  : — 
B. — Massae  ex  Hydrargy.  gr.  x; 
Pulv.  Ipecac,  gr.  i. 
M.  ft.  pil.  ii. 
A  mild  laxative  in  dyspepsia  and  disorders  of  the  stomach 
and  liver. 

R. — Extr.  Colocynth.  c; 
Massge  ex  Hydrargy. 
Pulv   Rhei.  v.  Jalapae,  aa  gr.  x; 
Ant.  et.  Potassae  Tart.  gr.  ^V. 

O  lb 

M.  ft.  pil   V. 
An  active,  antibiiious  purgative,  from  three  to  five  being  an 
ordinary  dose.     Calomel  may  be  substituted  for  the  blue  mass, 
if  there  is  much  disorder  of  the  liver  and  secretions. 

The  safest  emetics  are  ipecacuanha,  infusion  of  eupatorium 
pcrfoliatum,  and  mustard  and  common   salt,  an   even   table- 


88  MILITARY  SURGERY. 

spoonful  of  each  to  half  a  pint  of  tepid  water,  one-half  to  be 
taken  at  once,  the  remainder,  if  necessary,  in  fifteen  minutes. 
Sulphate  of  copper  or  zinc  will  afford  the  most  prompt  emetic 
effect  in  case  of  great  urgeocy,  as  in  poisoning. 

The  following  formula  will  be  found  very  serviceable  in  the 
earlier  stages  of  most  inflammatory  affections,  especially  the 
cutaneous,  articular,  and  traumatic,  unaccompanied  by  dis- 
ease of  the  alimentary  canal : 

B. — Ant  et  Potass.  Tart.  gr.  iss; 

Magnesias  Sulph.  ^i; 

Morphias  Sulph.  gr.  ss; 

Sacch.  Albi.  ^ii. 

Aquas  Destil.  ^vi.  M. 
This  is  the  antimonial  and  saline  mixture,  of  which  repeated 
menti'bn  occurs  in  the  preceding  pages,  and  which  I  am  in  the 
daily  habit  of  prescribing  in  my  surgical  as  well  as  medical 
practice.  It  may  be  rendered  depressant  by  the  addition,  to 
each  dose, —  which  is  half  an  ounce,  repeated  every  two  or 
three  hours, — of  from  three  to  eight  drops  of  the%tincturo  of 
veratrum  viride;  anodyne,  or  diaphoretic,  by  laudanum,  or 
morphia;  anti-periodic,  by  quinine;  anti-gonorrhoeal,  by  co- 
paiba, gum-arabic  beiug  used,  in  the  latter  case,  as  one  of  the 
ingredients;  and  anti-rheumatic,  by  colchicura.  If  quinine  be 
used,  the  addition  of  aromatic  sulphuric  acid  will  be  required, 
which  is  also  an  excellent  solvent  of  the  salts. 
R. — Vini  Colchici  Seiii.  ^i; 

Morphias  Sulph.  gr.  ss; 

Potassae  Carbon   gr.  x  ; 

Aqu^  Destil.  ^ss.     M. 
In  rheumatic  and  gouty  affections,  taken  at  bedtime,  and  fol- 
lowed by  a  mild  aperient  next  morning. 

The  following  will  be  found  to  be  pleasant  and  efficient 
d  iapho  ret  txts  : — 

R. — Spirit.  Mindereri,  ^iv; 

Sp   .^ther,  Nitrici.  ^ii ; 

Morphias  Acet.  gr.  i.     M.  S. 


MILITARY   SURGERY.  89 

Taijespoonful  every  two  or  three  hours.     If  there  be  much 
beat  of  surface,  we  may  add   to  each  dose  the  eighth,  twelfth 
or  fifteenth  of  a  grain  of  tartar  emetic. 
R. — Potassa3  Carbon,  s'l; 

Morphige  Sulph.  gr.  i; 

Sacch.  Albi.  5ii ; 

Sue.  Limonis  recent,  ^ii; 

Aquse  Month,  v.  Destil.  ^iiiss. 

Sp.  ^ther.  Nitrici.  ^ss.     M.  S. 
Tablespoonful  every  hour  or  two. 

The  effervescing  draught,  so  valuable  in  irritability  of  the 
stomach,  is  composed  as  follows: — 

R. — Sue.  Limonis  recent,  ^ji; 

Sacch.  Albi.  S^jiss; 

Aquae  Destil.  ^ij.     M. 
B. — Potassae  Carbon.  31; 

Aquae  Destil.  ^ij.     jNI. 
Put  two  tablespoonfuls  of  the  lemonade  with  one  of  the  alka- 
line solution,  and  let  the  mixture  be  drunk  while  effervescing, 
repeating  the  dose  at  pleasure. 

As  antiperiodics  quinine  and  arsenic  are  the  main  reliance 
of  the  modern  practitioner.  The  former  may  be  given  by 
itself,  in  pill  or  solution,  in  doses  var3itig  from  two  to  ten 
grains,  according  to  the  urgency  of  the  case  or  the  state  of 
the  system.  My  usual  dose  is  ten  grains  every  eight,  ten,  or 
twelve  hours,  until  the  paroxysm  is  arrested.  If  the  symp- 
toms are  unusually  violent,  we  need  not  hesitate  to  administer 
fifteen  jor  even  twenty  grains  at  a  do.se,  being  of  course  careful 
to  watch  the  effects,  which  will  generally  be  more  pleasant  if 
a  little  morphia  be  combined  with  the  quinine. 

In  chronic,  or  frequently  recurring  intermittent  and  neu- 
ralgic affections,  arsenic  forms  a  valuable,  and,  indeed,  ia 
many  cases,  an  indispensable  addition;  also  iron,  if  there  be 
evidences  of  anjemia.  I  prefer  myself  the  arsenious  acid  to 
Fowler's  solution,  convinced  that  it  is  much  more  eflicacious 


90  MILITARY   SURGERY. 

and  a^  the  same  time  less  apt  to  cause  nausea  and  anasarca. 
The  followintr  formuia  will  be  found  advantageous  : 
R.-'^Acid.  Arspniosi,  gr.  iss  ; 
Quiniae  Siilph. 
Feiri  Sulph   aa  ^i ; 
Morphise  Sulph.  gr.  i; 
Extr.  Nucis  Vomicae,  9i. 
M.  ft  pil.  XXX 
S.  One  every  five,  six  or  ei<»;ht  hours. 

Quinine  is  also  one  of  the  best  tonics,  and  it  may  always  be 
beneficially  conibiuLid  with  other  articles,  as  iron,  gentian, 
quassia,  nux  vomica,  and  cap.sicnm.  The  fluid  extrnots  and 
aromatic  tinctures  of  bark  and  gentian  will  also  be  found  use- 
ful. One  of  the  best  chalybejUe  preparations  is  the  tincture 
of  the  chloride  of  iron,  in  doses  of  from  twenty  to  twcnty-fivo 
drops  three  or  four  times  daily. 

Expectorants  constitute  a  large  class  of  remedial  agents, 
but  they  nearly  all  derive  their  active  principles  from  the  ad- 
mixture of  tartar  emetic,  ipecacuanha,  or  squills.  They  may 
generally  be  usefully  combined  with  potassa  and  anodynes, 
being  rendered  palatable  by  syrup  or  sugar. 

Nurses  should  be  familiar  with  the  manner  of  administer- 
ing enemata  or  injections,  as  frequent  occasions  arise  for  their 
employment.  They  may  be  cathartic,  as  when  they  are  de- 
signed to  euipty  the  lower  bowel,  or  to  promote  the  action  of 
other  remedies;  stimulant,  as  in  case  of  excessive  exhaustion; 
nutritive,  as  when  food  cannot  be  taken  by  the  mouth ;  ano- 
dyne, when  it  is  wished  to  allay  pain  and  induce  sleep., 

A  cathartic  effect  may  readily  be  induced  by  an  injection 
of  a  pint  and  a  half  of  cold  water,  or  water  in  which  a  little 
ground  mustard  or  common  salt  has  been  stirred,  a  mixture  of 
warm  water  and  castor  oil,  or  an  infusion  of  senna,  or  senna 
and  Epsom  salts.  Turpentine  is  particularly  indicated  when 
the  bowels  are  distended  with  flatus. 

Stimulating  injections  may  be  made  of  brandy,  alcohol, 
mustard,  salt,  or  spirits  of  camphor  or  turpentine,  mixed  with 


MILITARY  SURGERY.  91 

more  or  less  water ;  and  they  are  often  extremely  serviceable 
in  promoting  reaction. 

Nutritive  eneinata  may  be  necessary  in  the  low  stages  of 
fever,  and  in  gunshot  and  other  injuries  attended  with  lesion 
of  the  gullet.  The  best  ingredients  are  essence  of  beef,  strong 
beef-tua,  brandy,  or  bramly  and  milk,  introduced  in  small 
quantity,  so  as  not  to  oppress  and  irritate  the  rectum. 

Anodijne  injections  may  cfcnsist  of  laudanum,  black  drop, 
morphia,  hyoscyamus,  or  bclla<h)nna,  either  alone,  or  variously 
coMibined,  and  administered  with  about  two  ounces  of  tepid 
water,  or  some  demulcent  fluid. 

The  best  syringe  now  in  use  is  the  gutta-percha,  which  is 
not  liable  to  be  deranged,  and  which  has  the  additional  ad- 
vantage of  durability.  It  should  be  of  various  capacities, 
from  eight  to  sixteen  ounces,  according  to  the  intention  to  be 
fulfilled  by  it.  The  nozzle  must  be  well  oiled  previou.sly  to 
its  introduction,  and  care  taken  that  no  air  be  pushed  into  the 
bowel. 

2. —  Topical  Remedies. 

B. — Tinct.  lodinae, 

Sp.  Vini  Rectific.  aa  .f  j.     M. 
To  be  applied  with  a  large  camel-hair  pencil,  or  cloth  mop. 
I  hardly  ever  use  ihe  pure  tincture  of  iodine  for  local  pur- 
poses. 

R. — Plumbi  Subacet.  ^j ; 
Pu!v.  Opii,  3i.     M. 
To  be  put  in  half  a  gallon  of  hot  water,  and  the  solution  to  be 
used  warm  or  cold,  as  may  be  deemed  best.     Laudanum  may 
be  substituted  for  the  opium. 

R. — Pulv.  Ammoniae  Hydrochlor.  ^ j  ; 
**     Potassse  Nitrat.  ^ij ; 
"     0pii,3j.     M. 
To  be  used  as  the  preceding;  being  particularly  valuable  in 
inflammation  of  the  joints,  on  unbroken  surfaces. 

The  warm  water-dressing  consists  of  warm  water,  simple  or 


92  MILITARY  SURGERY. 

medicated  with  laudanum,  acetate  of  lead,  or  any  other  ir^ 
gredient  that  may  be  desired,  applied  upon  flannel  or  muslin 
cloths,  properly  folded,  and  covered  with  oiled  silk,  to  confine 
heat  and  moisture. 

The  cold  loater-dressmg  is  composed  of  cold  water,  also 
simple  or  medicated,  applied  with  cloths,  the  parts  being  con- 
stantly exposed  to  the  air  to  prevent  evaporation.  The  cloths 
are  to  be  wet  whenever  they  become  heated  or  dryish,  the 
water  being  pressed  upon  them  from  a  sponge. 

Water-dressings,  if  long  continued,  will  occasionally  cause 
irritation,  itching,  and  pustulation  of  the  skin,  rendering  it 
necessary  to  replace  them  with  cataplasms,  or  other  soothing 
remedies. 

Among  poultices  decidedly  the  best,  for  ordinary  purposes, 
are  the  flaxseed  and  slippery  elm.  The  former  is  made  by 
mixing  a  suitable  quantity  of  linseed  meal  with  hot,  or,  what 
is  still  better,  boiling  water,  and  rapidly  stirring  it  into  a  thick 
mush-like  consistence.  The  mixture  is  then  spread  upon  a 
fold  of  cloth,  in  a  layer  a  third  of  an  inch  thick,  when  it  is 
covered  with  bobinet  or  gauze  to  prevent  it  from  adhering  to 
the  parts.  A  piece  of  oiled  silk,  larger  than  the  poultice,  is 
placed  upon  its  outer  surface,  to  retain  heat  and  moisture. 

The  elm,  and,  in  fact,  all  other  cataplasms,  are  prepared 
and  used  upon  the  same  principles  as  the  linseed.  Like 
water-dressings,  poultices  may  be  simple  or  medicated,  ac- 
cording to  the  object  proposed.  They  should  be  changed  at 
least  twice,  or,  in  warm  weather,  even  three  or  four  times"  in 
the  twenty-four  hours. 

Adhesive  plaster  is  cut,  in  the  direction  of  its  length,  into 
strips  of  suitable  length  and  breadth,  warmed  by  holding  the 
backs  against  a  smooth  vessel,  as  a  pitcher  ar  tin  case,  and 
applied  in  such  a  manner  as  to  bring  the  middle  of  each  piece 
over  the  wound,  the  edges  of  which  are,  meanwhile,  carefully 
supported  by  an  assistant.  A  suitable  space  is  left  between 
the  strips  for  drainage.  If  things  progress  favorably,  substi- 
tution need  not  be  made  under  three  or  four  days.     If  the 


MILITARY  SURGERY.  93 

Vouud  be  large,  only  a  few  of  the  strips  are  taken  off  at  a 
time,  lest,  all  support  being  lost,  the  edges  should  be  forcibly 
separated. 

Before  the  soiled  dressings  are  removed,  everything  in- 
tended for  the  new  should  be  prepared,  or  .put  in  its  proper 
place.  The  strips  of  plaster  must  be  removed  with  great 
gentleness  • 

If  the  injured  parts  are  covered  with  hair,  the  surface  must 
always  be  shaved  before  the  application  of  the  dressings. 

Proper  material  for  sutures  should  always  be  kept  on  hand, 
ready  for  use.  The  silver  wire  is  the  best,  as  it  is  less  irri- 
tating than  any  other.  Silk,  however,  answers  exceedingly 
well;  the  thread  should  be  rather  thin,  and  be  well  waxed. 
Saddler's  silk  is  the  article  used  for  the  ligation  of  large 
arteries. 

Among  the  more  common  and  useful  unjuenis  for  dress- 
ing wounds,  burns,  abraded  surfaces,  or  fissures,  are  the  fol- 
lowing : 

R. — Pulv.  Opii,  5^s; 
Pulv.  Pvhei,  Bi; 
Ung.  Cetacei,  ^i.     M. 
To  these  ingredients  may  advantageously  be  added,  in  many 
cases  of  healing  sores,  or  eruptions,  requiring  a  mild  stimulus, 
a  drachm  of  the  ointment  of  the   nitrate  of  mercury,  a  few 
drops  of  nitric  aci4,  two  drachms  of  ointment  of  acetate  of 
lead,  a  small  quantity  of  myrrh,  or  of  balsam  of  Peru,  or 
from  six  to  eii^ht  grains  of  sulphate  of  quinine. 
R.— Ung.  Cetacei,  5j ; 

Bismuth.  Subnitr.  jij.     M. 
Extremely  soothing  and  valuable  in  superficial  excoriations, 
slight  burns,  and  eczematous  aftections.     Turner's  cerate  may 
be  employed  for  similar  purposes,  but  should  always  be  con- 
siderably diluted. 

The  best  disinfectants  are  the  chloride  of  soda,  chloride  of 
lime,  Labarraque's  solution  and  the  hypermanganate  of  po- 
tassa,  of  which  an  abuudaat  supply  should  always  be  on  hand 


94  MILITAKT  SURGERY. 

in  every  hospital,  free  use  of  it  being  made,  by  sprinkling  an(f . 
otherwise,  upon  the  dressings,  as  well  as  upon  the  bedding  and 
the  rooms. 

The  sponges  about  a  hospital  should  be  of  the  softest  kind, 
perffictly  clean,  and  always  ready  for  use.  The  same  articles 
should  never  be  employed  upon  different  persons,  especially  , 
where  there  are  foul  or  specific  sores,  as  contagion  might  thus 
be  communicated  by  direct  inoculation,  as  has,  for  example, 
so  often  happened  during  the  prevalence  of  hospital  gangrene. 

3.- — Dietetic  Preparations. 

The  diet  of  the  sick-room  has  slain  its  thousands  and  tens 
of  thousands.  Broths,  and  slop?,  and  jellies,  and  custards, 
and  ptisans  are  usually  as  disgusting  as  they  are  pernicious. 
Men  worn  out  by  disease  and  injury  must  have  nutritious  and 
concentrated  food.  The  ordinary  preparations  for  the  sick 
are,  in  general,  not  only  nutritious,  but  insipid  and  flatulent. 
Nitrogenous  food  is  what  is  needed,  even  if  the  quantity  taken 
be  very  small.  Animal  soups  are  among  the  most  efficient 
supporters  of  the  exhausted  system,  and  every  medical  man 
should  know  how  to  give  directions  for  their  preparation. 
The  life  of  a  man  is  his  food.  Solid  articles  are,  of  course, 
withheld  in  acute  diseases,  in  their  earlier  stages,  but  when 
the  patient  begins  to  convalesce  they  are  frequently  borne 
with  impunity,  and  greatly  promote  recovery.  All  animal 
soups  should  be  made  of  lean  meat;  and  their  nutritious 
properties,  as  well  as  their  flavor,,  may  be  much  increased  by 
the  addition  of  some  vegetable  substance,  as  rice  or  barley. 
If  the  stomach  is  very  weak,  they  may  be  diluted,  or  seasoned 
with  pepper. 

Essence  of  heef  so  frequently  given  in  the  low  stages  of 
fever,  and  in  the  exhaustion  consequent  upon  severe  injuries 
and  operations,  is  prepared  by  cutting  from  a  quarter  to  half 
a  pound  of  lean  beef  into  thin  pieces,  and  putting  it  into  a 
wide-mouthed  porter  bottle,  corked  tightly,  and  placed  in  a 
kettle  of  cold  water,  which  is  then  heated  till  it  boils.     After 


MILITAIIY   SURGERY 

it  has  been  digested  in  this  way  for  a 

decanted,  and  seasoned  with  salt  and 
Btef  tea,  much  less  nourishing  t-, 

by  putting  a  quarter  of  a  pound  o' 

half  of  water,  and  boiling  it  for 

of  mace  being   added  during  th 

skimmed. 

To  make  chicken  hroth  requ'< 

quart  of  cold  wat^r,  with  a  V 

whole   being  slowly  boiled   : 

proper  skimming. 

Chicken  jelly  is  prepared 

all  the  bones  broken,  in  a  • 

tained  in  boiling  water  for  t 

is  then  strained,  and  season 
Veyetalle  soup  h  compo» 
and  a  piece  of  bread,  witl 
pint  in  a  closely-covered  ^ 
introduced  near  the  close 
are  added  at  pleasure. 

To  form  rice  Jcliy  a  < 
twice    that  quantity  of 
water,  until  the  wh  le   ' 
jelly  is  strained  off  and 
S'ljn  jfUy  is  compo, 
quart  of  water,  juice  ai 
to  render  it  agreeable, 
hour,  it  is  boiled  until  a 
the  mass  being  constant' 
Oatmeal  yruel  is  coi 
meal  and  a  half  pint  o' 
water,  and  allowed  to 
strained  through  a  hai 
a  similar  manner. 

Arrow-root  pajp    cf 

subatuDce  made  into  ? 


'ILITARY   SURGERY. 

■  pf  boiling  water,  and  kept  on  the  fire 
;  nourishing  properties  of  arrow-root 
by  using  milk  instead  of  water  in  its 

1  relished  by  the  sick ;  and  there  is 

^valids  made  of  a  thinly  sliced  and 

iled  in  a  quart  of  water  until  it 

n  it  should  be  strained  upon  a 


various  dietetic  preparations 
acreased  by  the  addition  of 
7hen  salt,  or  salt  and  pepper 
''hould  be  consulted.  Great 
g  these  compounds  that  they 
i  a  double  boiler  should  be 


when  a  stimulant  is  re- 

^,  is  made  by  mixing  good 

proportion  of  about  one 

f  the  latter.     Sugar  and 

xture  palatable. 

lered  of  great  service  to 

♦^^0  a  pint  of  fresh  milk, 

as  much  good  Madeira 

Ixture  is  then  strained 

deira,  Port  and  Sherry, 
ne  sometimes  produces 
ih  as  well  as  the  system 

te  and  yolk  of  which 
.f  cold  water  with   a 
with  two  tablespoon- 
's: Now  printing  from  tiae 


'•:/k/-cr-' 


